I '!;i, 




Class _Jlr^^_123_ 
Book ^X^ 

CDPifKIGHT DEPOSm 



THE 
CASE HISTORY SERIES 



CASE HISTORIES IN MEDICINE 

BY 

Richard C. Cabot, M.D. 

Third edition, revised and enlarged 



CASE HISTORIES IN PEDIATRICS 

BY 

John Lovett Morse, M.D. 

Second edition, revised and enlarged 



ONE HUNDRED SURGICAL PROBLEMS 

BY 

James G. Mumford, M.D. 
Second Printing 



CASE HISTORIES IN NEUROLOGY 

BY 

E. W. Taylor, M.D. 

Second Printing 



CASE HISTORIES IN OBSTETRICS 

BY 

Robert L. DeNormandie, M.D. 

Second Edition 



CASE HISTORIES IN DISEASES OF WOMEN 

BY 

Charles M. Green, M.D. 



CASE HISTORIES 



IN 



OBSTETRICS 

GROUPS OF CASES ILLUSTRATING THE 

FUNDAMENTAL PROBLEMS WHICH 

ARISE IN OBSTETRICS 



./ 



BY 



ROBERT L; DeNORMANDIE. A.B.. M.D., F.A.C.S. 

Assistant m Obstetrics, Harvard Medical School ; Assistant Physician, 

Bostoa Lying-in Hospital ; Surgeon to the Gynecological 

Department of the Boston Dispensary 



SECOND EDITION 




BOSTON 

W. M, LEONARD, PUBUSHER 

1917 






.-' 



Copyright, IQ14, 

Copyright, igiy, 

By W. M. Leonard 



MM -3 1917 



To 
FRANKLIN S. NEWELL, M.D. 

Assistant Professor of Obstetrics and Gynecology 
Harvard Medical School 

An Able Obstetrician and a True Friend 
Tins Book is Dedicated 



PREFACE 

When a student in the Harvard Medical School, some of 
the most valuable teaching that I received in Obstetrics was 
from the conferences which were then held, based on the clini- 
cal reports of cases. At that time I was firmly convinced of 
the value of such teaching. 

The cases here recorded are all actual ones which have oc- 
curred in my private or hospital work. The technique ad- 
vised in the cases is that which any conscientious physician 
can carry out if he wishes. 

If a study of these cases stimulates even a few physicians 

to seek a higher standard in their obstetric work this book will 

not have been written in vain. 

Robert L. DeNormandie 
357 Marlborough Street 



PREFACE TO SECOND EDITION 

In this second edition I have made corrections throughout 
the book to clarify the meaning of the text. Some of the 
sections have been materially altered, namely Section IX, 
on Accidental Hemorrhage of Pregnancy; Section XVI, on 
Sepsis; Section XVIII, on Pyelitis in Pregnancy; Section 
XXI, on Scopolamine Morphine Anaesthesia. 

A few words have been added about the use of nitrous 
oxide in obstetrics and various notes on the further history of 
some of the cases cited have been added. 

The very friendly and honest criticisms that the reviewers 
throughout the country have made of the book have been 
very gratifying and the fact that the first printing has been 
sold leads me to feel that the book has at least a slight place 
among the obstetric works of to-day. 

Robert L. DeNormandie 

355 Marlborough Street, 
Bostoriy Massachusetts. 



CONTENTS 



Section I. Diagnosis of Pregnancy. 



Case 



I. 
II. 

III. 
IV. 



Section II. 

Case 
V. 
VI. 
VII. 

VIII. 



Diagnosis of Pregnancy 17 

Diagnosis of Pregnancy. Question of Extrauterine Preg- 
nancy 19 

Diagnosis of Pregnancy. Error in Diagnosis 22 

Diagnosis of Pregnancy. Decidual Cast 27 

Summary of Diagnosis of Pregnancy 31 

Miscarriage. 

Inevitable Miscarriage 35 

Threatened Miscarriage 37 

Retroverted Incarcerated Pregnant Uterus. Blighted 

Ovum 40 

Automobile Miscarriage 44 

Summary of Miscarriage 45 



Section III. Normal Pregnancy. 



Case 



IX. 

X. 

XI. 

XII. 

XIII. 
XIV. 



Section IV. 

Case 
XV. 
XVI. 



Normal Muciparous Pregnancy. Labor, Occiput Left 

Anterior 53 

Normal Delivery. Occiput Right Posterior 60 

Normal Pregnancy and Labor. Occiput Left Anterior 64 
Normal Multiparous Labor. Occiput Right Posterior. 

Retained Membranes 68 

Normal Pregnancy and Labor. Slight Hemorrhage. Shock 74 

Primiparous Labor. Occiput Right Posterior 79 

Summary of Normal Pregnancy 82 

The Physician's Outfit 96 

The Mother's Outfit 99 

Preparations for the Delivery loi 

Technique of Normal Delivery 106 

The Puerperium 122 

Obstetric Ether 130 

Nitrous Oxide and Oxygen Anaesthesia 131 

Forceps. 

Low Forceps. Occiput Fully Rotated 133 

Low Forceps. Irregular Fetal Heart 136 

II 



12 



CONTENTS 



Case 
XVII. 
XVIII. 
XIX. 

XX. 

XXI. 
XXII. 



Low Forceps. Occiput Right Posterior. Rigid Coccyx 139 
Partial Manual Dilatation of Os Uteri. Low Forceps 143 
Occiput Left Posterior. High Forceps. Double Applica- 
tion 147 

Occiput Left Anterior. Edematous Anterior Lip of the 

Cervix. High Forceps 151 

Occiput Right Posterior. Manual Dilatation. High Forceps 154 
Occiput Left Anterior. Contraction Ring. High Forceps. 

Flat Pelvis 158 

Summary of the Technique of Forceps Delivery 160 



Section V. Breech Delivery. 

Case 

XXIII. Multiparous Breech Delivery 173 

XXIV. Primiparous Breech Delivery 175 

XXV. Breech Extraction. Dry Uterus. Contraction Ring . . 180 

XXVI. Primiparous Breech Extraction 183 

XXVII. Multiparous Breech. Voorhees Bag 188 

Summary of Breech Delivery and Extraction ...... 189 



Section VI. Multiple Pregnancy. 



Case 

XXVIII. Twins. 

tion 

XXIX. Twins. 

XXX. Twins. 



O. D. A. Low Forceps. S. L. A. Breech Extrac- 



O. L. A. O. D. P. Normal Deliveries 
Double Footling. Extraction. Sc. L. A. 



Version 



Summary of the Management of Multiple Pregnancy 



199 
203 
206 
208 



Section VII. Prolapsed Cord. 



Case 
XXXI. 
XXXII. 
XXXIII. 



Prolapsed Cord. Version 211 

Prolapsed Cord. Version 214 

Prolapsed Cord. Low Forceps 217 

Summary of the Management of Prolapsed Cord .... 224 



Section VIII. Version. 



Case 
XXXIV. 

XXXV. 
XXXVI. 



Version. Flat Pelvis. Post-partum Hemorrhage .... 229 

Management of Post-partum Hemorrhage 233 

Flat Pelvis. Elective Version 238 

Flat Pelvis. Elective Version. Forceps to After-coming 

Head 240 

Summary of Indications for and Technique of Version 241 



CONTENTS 



13 



Section IX. Accidental Hemorrhage of Pregnancy. 
Case 
XXXVII. Premature Separation of a Normally Implanted Placenta 249 
XXXVI I A. Premature Separation of a Normally Implanted Placenta 251 
Summary of Accidental Hemorrhage in Pregnancy .... 252 

Section X. Unavoidable Hemorrhage of Pregnancy. 

Case 
XXXVIII. Partial Placenta Praevia. Manual Dilatation. Version. 

Extraction 255 

XXXIX. Separation of a Low Attached Placenta. Puerperal Sal- 
pingitis 259 

Summary of Puerperal Salpingitis 263 

XL. Complete Placenta Praevia. Voorhees Rubber Bag Followed 

by Version . 266 

Summary of Placenta Praevia 268 



Section XI. Contracted Pelvis. 

Case 

XLI. Contracted Pelvis. Intermediate Forceps 277 

XLII. Contracted Pelvis. Elderly Primipara. High Forceps 282 

XLIII. Contracted^Pelvis. Posterior Parietal Presentation . . . 288 

XLIV. Contracted Pelvis. High Forceps 290 

XLV. Contracted Pelvis. Caesarean Section 292 

XLVI. Caesarean Section because of Past Operative Obstetric 

History 294 

XLVI I. Contracted Pelvis. Craniotomy 296 

Technique of Craniotomy 298 

Summary of Contracted Pelvis 301 



Section XII. Nausea and Vomiting of Pregnancy. 

Case 

XLVIII. Nausea and Vomiting of Pregnancy 305 

XLIX. Nausea and Vomiting of Pregnancy. Induction of Labor. 

Recovery 308 

Summary of Nausea and Vomiting of Pregnancy .... 310 



Section XIII. Toxemia of Pregnancy and Eclampsia. 

Case 

L. Toxemia of Pregnancy. Induction of Labor 313 

LI. Toxemia of Pregnancy. Induction of Labor. Forceps. . 318 

LI I. Toxemia of Pregnancy. Low Forceps 325 

LIII. Toxemia of Pregnancy. Contracted Pelvis. Caesarean 

Section 331 

LIV. Eclampsia. Vaginal Caesarean Section 335 



14 CONTENTS 

PAGE 

Case 

LV. Eclampsia. Palliative Treatment Followed by Vaginal 

Caesarean Section 337 

Summary of the Toxemia of Pregnancy and Eclampsia 341 

Section XIV. Face Presentation. 

Case 

LVI. Face Presentation. Chin Posterior. Internal Podalic 

Version 351 

LVI I. Face Presentation. Chin Anterior. Internal Podalic 

Version 353 

Summary of Face Presentations 355 

Section XV. Transverse Presentation. 

Case 
LVIII. Transverse Presentation. Internal Podalic Version . . . 357 
Summary of Transverse Presentations 359 

Section XVI. Sepsis. 

Case 

LIX. Puerperal Sepsis. Retained Secundines ........ 361 

LX. Uterine Sepsis 364 

Summary of Treatment of Sepsis 365 

Section XVII. Phlebitis. 

Case 

LXI. Double Phlebitis 373 

Summary of Phlebitis 375 



Section XVIII. Pyelitis in Pregnancy and in the Puerperium. 

Case 

LXII. Pyelitis in Pregnancy 379 

LXI 1 1. Pyelitis in the Puerperium 383 

Summary of Pyelitis in Pregnancy and in the Puerperium 386 



Section XIX. Mastitis and Breast Abscess. 

Case 

LXIV. Acute Mastitis 389 

LXV. Breast Abscess. Incision under Ether 391 

" LXVI. Acute Mastitis. Lactation Stopped 393 

LXVII. Mastitis. Breast Abscess. Bier Suction Bells 395 

Summary of Mastitis and Breast Abscess 397 



CONTENTS 



Section XX. Heart Disease in Pregnancy. 



15 



Case 

LXVIII. Pregnancy with Mitral Regurgitation. Normal Delivery 405 
LXIX. Mitral Regurgitation. Early Rupture of the Membranes. 

Voorhees Bag. Forceps Delivery 412 

Summary of Heart Disease in Pregnancy 418 

Section XXI. Scopolomine and Morphine Anaesthesia. 

Case 
LXX. Scopolomine and Morphine Anaesthesia in Labor 421 

Section XXH. Puerperal Insanity. 

Case 
LXXI. Puerperal Insanity 425 

Summary of Puerperal Insanity 434 

Section XXIII. The Hydrostatic Dilating Bags. 

Case 

LXXI I. Intermediate Forceps. Voorhees Bag 439 

The Use of Hydrostatic Dilating Bags 443 

Section XXIV. Ruptured Uterus. 

Case 

LXXI 1 1. Incomplete Rupture of the Uterus 447 

Summary of Ruptured Uterus _ 45^ 

Section XXV. Hydramnios. 

Case 

LXXIV. Acute Hydramnios 455 

Management of Cases Presenting Hydramnios 462 

Section XXVI. Cicatrix in Vagina Complicating Labor. 

Case 

LXXV. Multiparous Labor. Cicatrix in the Vagina. Manual 

Dilatation. High Forceps 467 

Section XXVII. Pneumonia Complicating Pregnancy. 

Case 
LXXVI. Pneumonia Complicating Pregnancy 473 

Section XXVIII. The Baby. 

The Management of the Baby 477 



SECTION I. 
DIAGNOSIS OF PREGNANCY. 

Case I. Patient presents herself at the office August 23rd 
with the question of pregnancy. The history that she gives 
is that her last menstruation began on June 14th. It was 
normal in amount and character, with the exception that 
one day she had severe pain, which for her was unusual. 
That day she rested quietly in her room and the next day 
got up and was about as usual. Her May period was normal. 
There was no July period and up to the present time there 
has been no period in August. Her menstruation began 
when thirteen years of age. She flows regularly every 
twenty-eight days for five days, using three napkins a day 
for the first three days and then one each day. On July 22nd 
she first noticed that she had very slight nausea. From 
then, until the first of August she has been nauseated 
frequently sometimes in the morning and sometimes in the 
afternoon or evening. Since the first of August she has not 
been nauseated at all, but has noticed that if her husband 
is smoking and the room is at all close the smoke nauseates 
her. She says she is rather languid and inclined to sleep. 
She gets up at night to pass her water once, and during the 
day she passes it five or six times when previously she passed 
it only three times during the day and not at all during the 
night. Bowels are regular without medicine. For the last 
few days she has noticed that there has been some tingling 
in the breasts, especially about the nipples. 

Vaginal Examination : — No increased blueness of the 
introitus. Slight increase in the amount of secretion. Cer- 
vix feels soft and is of conical shape. The uterus is slightly 
anteflexed and there is a distinct softening at the junction 
of the cervix with the body of the uterus. The uterus is 
definitely enlarged. The whole uterus seems to be about 
the size of an orange. 

17 



1 8 CASE HISTORIES IN OBSTETRICS. 

Examination of the Breasts: — They are very firm, 
veins are prominent and the glands of Montgomery are dis- 
tinctly enlarged. When her attention is called to the areola 
she says she is quite sure it is much larger and darker than it 
has ever been before. 

Diagnosis : Pregnancy is probable. 

She was told to go on the principle that she was pregnant, 
and I went over with her the care that she should take of 
herself during pregnancy. She is to report again in a month's 
time when a definite diagnosis can readily be made. If her 
dates are right labor should be due March twenty-first to 
twenty-eighth. 

October 5. She writes to-day asking if she can take an 
automobile trip through the White Mountains and that she 
is feeling very well. She is quite positive that she is preg- 
nant because her breasts are rapidly enlarging and she is 
increasing in weight and no period has returned. She was 
not allowed to go on the automobile trip. 

Further history of this patient is that she was pregnant 
at the time seen and she came into labor and was delivered 
March 26th. 



DIAGNOSIS OF PREGNANCY. I9 

Case 2. Question of Extra-uterine Pregnancy. June 
14. Patient presents herself at the office to-day with the 
following story : — She wants to know if she is pregnant. 
Her last child, which was the second, was born thirteen 
months ago. She nursed this child for nine months. Men- 
struation returned seven months after the birth of this child. 
Since then menstruation has been regular, every twenty-eight 
days. She uses from six to eight napkins in all. Her last 
menstruation was on April 29, one week late. There was no 
period in May. She is doubtful about this pregnancy because 
she says that she has worn a pessary, because of a retro- 
verted uterus, since the first child was born, that she did not 
conceive the second time until the pessary was removed, and 
that now at no time has the pessary been removed. Another 
reason why she doubts pregnancy is that in her two previous 
pregnancies by this time, six weeks, she was in bed with nausea 
and vomiting and now she has but very slight nausea and no 
vomiting. 

She thinks she is pregnant because she has the longings for 
the queer things to eat and a definite aversion to certain other 
things which she had in her previous pregnancies. She now 
has marked hunger between her meals with a sense of empti- 
ness. In May, when her period should have come, she re- 
members having had definite prickling sensations in her 
breasts. Her bowels are regular with medicine. There is 
no change in micturition. 

At two different intervals in the past six weeks she has 
noticed that she has had severe sharp pain on the right side, 
so severe that she had to sit down for a few moments. She 
did not faint and there was no nausea accompanying the 
pain. For five years, up to five years ago, she says that she 
had this right-sided pain and the doctor, who was then look- 
ing after her, told her the pain was due to an enlarged ovary. 
Several times she says that the tenderness has been so great 
that she could not bear the pressure of her clothes and had 
to go to bed because of it. 

Vaginal Examination: — The pessary was removed. 
There is no blueness of the introitus. The cervix has a 
slight bilateral tear and feels soft. The uterus is slightly but 



20 CASE HISTORIES IN OBSTETRICS. ♦ 

distinctly enlarged and there is definite softening present be- 
tween the cervix and the body of the uterus. The lateral 
culs-de-sac give a sensation of slight fullness in the neighbor- 
hood of the uterus. The uterus is in normal position. On 
her left nothing is felt. On her right is a mass the size of a 
pullet's egg which when palpated is distinctly tender. It is 
firm and non-resilient. Inspection of the cervix shows no 
erosion present. 

Diagnosis: Pregnancy is probably present. An extra- 
uterine pregnancy must be considered, but the probability is 
that there is a normal pregnancy with an enlarged right 
ovary. 

In previous vaginal examinations upon this patient I had 
never felt this right-sided mass although I knew she had 
had previous pain on that side. The patient was planning 
to go away to her summer home some fifty miles from any 
surgical help and the question at once arose whether to allow 
her to go. I was unwilling to accept the responsibility of al- 
lowing her to go without a consultation for which I immedi- 
ately asked. My consultant saw her at once. His findings 
corresponded with mine except that he was more positive 
than I that the pregnancy was intra-uterine and not extra- 
uterine. He put more stress on her past history and the 
fact that she was known to have had for five years an ovary, 
which at times had bothered her considerably. We agreed to 
let her go to her summer home and I gave her the names of 
several surgeons for whom she could send in any emergency. 
I then told her she should be examined the first week in 
July. 

July 2. Although the nausea is marked it is not as bad 
as in the other two pregnancies. It is especially distressing 
after her evening meal and she then goes to bed. She has 
not had the slightest discomfort on the right side. Is feeling 
on the whole remarkably well. Vaginal examination shows 
that the uterus has distinctly enlarged since the previous 
examination. It now corresponds to a two-month's preg- 
nancy. Normal in position. Nothing is felt on the left 
side. On very careful examination of the right side I can- 



DIAGNOSIS OF PREGNANCY. 21 

not make out any mass and there is absolutely no tender- 
ness. 

I then told her there was no question in my mind that the 
pregnancy was intra-uterine and not to think any more about 
the possibility of an extra-uterine. 



22 CASE HISTORIES IN OBSTETRICS. 

Cases. Error IN Diagnosis. November 2. Patient pre- 
sents herself at the office to-day with the following story : — 
She has been told by a physician that she is pregnant. She 
is twenty-two years of age, and has been married sixteen 
months. Menstruation began when she was twelve years old. 
It comes every twenty-eight days and lasts for four days, 
and she uses in all ten napkins. She has no pains with the 
periods. She had a normal period July loth. On August 
20th she began to flow with severe pain and many clots. 
After two days of pain the excessive flowing stopped and 
at the end of five days all flowing had ceased. She stayed 
five days in bed at this time and she was told by the phy- 
sician who then had charge of her that she had had a mis- 
carriage. This physician made no vaginal examination. 
From August 25th until October 6th she had no flow. On 
that day she had a slight flow, dark brownish-red in color, 
on the next day it was a little more marked. She had very 
slight pain in the lower abdomen. Her own physician at 
that time put her to bed, told her she was pregnant and got 
a nurse for her. She was kept in bed from the sixth to the 
twenty-first of October with a nurse in attendance. Since 
October eighth, she has had no pains and no 'sign of any flow. 
She has been nauseated several times. Her bowels are reg- 
ular with medicine. There is no increase in micturition. 
Since October twenty- first she has been going about her 
house very slowly and carefully. As long as the diagnosis 
of pregnancy was definitely made by her own physician and 
as she is just getting about from a threatened miscarriage I 
decided not to examine her. She now considers herself about 
eight weeks pregnant. 

November 8. Telephone from the patient that she had a 
very slight show this morning which made a stain on her 
underclothes about the size of a fifty-cent piece. She was 
not having any pains. I told her to go to bed and went at 
once to her. When I saw her she said she was having a few 
pains, that she wanted to do everything she possibly could 
to avoid a miscarriage. I gave her one-eighth grain of 
morphia subcutaneously at once and told her if the pains 
did not cease in an hour's time to take the tablet (morphia 



DIAGNOSIS OF PREGNANCY. 23 

gr. 1/8) which I left her. I immediately got a nurse for her 
and told her she must stay in bed absolutely. I did not ex- 
amine her at this time. This evening about eight, pains 
returned and the morphia was repeated. At ten they were 
still present but less, and as she was very restless she was 
given another i /8 grain subcutaneously. 

November 9. Morphia which she had last night made 
her more or less delirious, but she has had no pain since ten 
last evening. Temperature normal. Pulse 62. No tender- 
ness over the abdomen. The fundus cannot be palpated. 
At the present time there is no flowing, but last night at five 
o'clock one pad was stained through with bright red blood. 
No clots. The next napkin had less stain and was darker 
in color. There has been absolutely no staining since nine 
this morning. She dates her pregnancy from about August 
27th, and if this is so she would be about ten weeks preg- 
nant. Examination of the breasts shows that the breasts 
are not enlarged, are soft and not firm. There is no en- 
largement of the glands of Montgomery. 

There is no indication for treatment except to keep the 
patient in bed on a light diet. 

November 13. Vaginal examination shows the uterus in 
third degree retroversion. Cervix is not softened. There is 
no enlargement on the sides but the whole uterus gives the 
impression of being slightly enlarged. The rest of the 
pelvic examination is not remarkable. 

The uterus is not enlarged to correspond to her supposed 
dates. If she is pregnant, it is not for more than a few weeks 
at most. 

Patient was put in the knee-chest position and I tried 
to replace the uterus but with the amount of manipulation 
that I felt justified in using could get it out of the posterior 
cul-de-sac, up only into second degree retroversion. I could 
not get the fundus forward. She is to get up to-morrow and 
go about slowly. There is to be no intercourse and she was 
forbidden to go out in the automobile. 

November 28. Since last note patient has been up and 
about the house. There has been no flowing and no pain. 
Vaginal examination shows the uterus in second degree ret- 



24 CASE HISTORIES IN OBSTETRICS. 

roversion. There is absolutely no tenderness in the pelvis. 
Cervix is slightly soft. I can make out no increase in the 
enlargement of the uterus from the last note and to-day 
there is a question in my mind whether she is pregnant at 
all. I suggested to her an ether examination but she is very 
apprehensive about taking ether and refused. She is per- 
fectly willing to go on in doubt for a time longer. 

December 5. Telephone from the patient that there is a 
slight show this afternoon. All flowing had stopped within 
an hour after it had begun. I saw her in the late after- 
noon and it was then seen that she had become very appre- 
hensive about herself. She says she is afraid to go in town 
and is afraid to get on to the cars and is afraid to stay alone 
in her home. Careful questioning brought out the fact that 
she had been having these fears for the past four months 
and that she had avoided telling me anything about them. 
She says she is sleeping poorly but that her appetite is good. 
Since she was married she says she has lost weight. Her 
best weight was two years ago when she weighed 155. Her 
usual weight is about 140, but that now she weighs 112. 

She is very nervous, unable to sit quietly, constantly 
getting up and biting her nails. Her talk is very rapid but 
perfectly coherent. She says this nervousness has all come 
on since she was married. She recognizes that she must 
control herself, but she says the fact that she may miscarry 
stirs her up constantly. She is talking with her friends and 
relatives of the possibility of miscarrying. Yesterday she 
had a hysterical attack and it was some hours before she 
got control of herself. 

I told her the important thing was, not that she might 
miscarry, but that she must overcome this extreme nervous- 
ness and put away these fears of which she speaks. The 
question of pregnancy must not be talked about with any- 
one. I then questioned her about the frequency of inter- 
course and she answered "quite often." I did not press this 
question but asked that her husband come to my office so 
that I could talk the situation over with him. 

December 6. The husband comes to the office to-day 
and he tells me that she is very much upset by the fact that 



DIAGNOSIS OF PREGNANCY. 25 

I asked him to come in and that she is sure there is '* some- 
thing terrible the matter" with her. I told him very clearly 
that I thought it wrong to put her to bed because of her 
mental condition, which had become very much worse in 
the past three weeks, that it was very much better to let 
her go about and if she did miscarry to make light of it; 
that I did not believe she was pregnant now and that if she 
were, her mental condition was such that this was more im- 
portant than the pregnancy. Questioning him about inter- 
course he frankly said that there had been a great excess, 
and that he now thought this might have something to do 
with her nervous condition. He agreed to abstain entirely 
for two months from any intercourse and said he would do 
all in his power to straighten out the situation at home. 

December 12. She has been sleeping better. During the 
day has had several depressed periods and was very much 
worried about her general condition. I examined her by 
vagina to-day in order to settle absolutely about her preg- 
nancy. There is no blueness in the vagina. Uterus is in 
second degree retroversion. There has been no enlarge- 
ment since my last note although the uterus seems a little 
larger than a virgin uterus should be. There is no erosion 
of the cervix. Examination of the breasts shows that they 
are soft and are not enlarged in size. Papillae although 
prominent are not markedly enlarged. There is no increased 
color of the areola. 

There is no question in my mind that she is not pregnant 
and that she has not been pregnant. She is disappointed 
but recognizes that her own mental condition is for the time 
being more important than any pregnancy. 

May 2"], Reports at the office to-day and is looking 
splendidly. Says she is feeling absolutely well. No sen- 
sations of depression or fear. The only time she is de- 
pressed at all is just before her menstruation, but then only 
for a few hours and it all passes over quickly. She now 
weighs 147, which is approximately her normal weight. 
She is sleeping well, her appetite is excellent. The January 
period was a little scant. The February period normal in 
all respects, as were also her March, April and May periods. 



26 CASE HISTORIES IN OBSTETRICS. 

Her general condition is satisfactory, and her mental con- 
dition is normal. She wants to know now about becoming 
pregnant and what advice I would give her about the retro- 
verted uterus. I told her that I was unwilling to give her 
ether and attempt to replace the uterus or to do any major 
operation until her husband's seminal secretion was examined. 
She volunteered the remark that she thought her nervousness 
was due entirely to the excessive amount of intercourse and 
that now since it had come within normal limits she would 
be perfectly well. 

Up to the present time she has not become pregnant and 
and her husband would not have his seminal fluid examined. 



J 



DIAGNOSIS OF PREGNANCY. 27 

Case 4. Decidual Cast. Patient is seen for the first 
time, February 3rd, when she comes to the office saying 
that she is pregnant. Her last period was December 6th. 
Absolutely normal in all respects. Lasted four to five days. 
Period comes every twenty-one to twenty-four days. She had 
no period in January. This is her second pregnancy. In the 
seventh week of her first pregnancy she started to flow. At 
first only a few stains which gradually increased until she used 
five or six pads a day. All this time she had no pain. Felt 
absolutely well and with no nausea. She was kept in bed 
during this flowing. She says it stopped after what cor- 
responded to the third menstrual period. After she stopped 
flowing she was allowed gradually to get up and about. At 
that time the physician in charge had several consultations 
about the advisability of emptying the uterus because of 
the flow, but it was finally decided to let her go on and 
pregnancy ended with a normal delivery after a twelve-hour 
labor. She had three stitches taken in the perineum. 
The baby weighed eight and a half pounds. She nursed 
her baby for nine months, five months entirely. After this 
first baby was born she had considerable bearing down sen- 
sation and backache and a year later she had an Alexander 
operation performed for a retroverted uterus. Since this 
operation she has been perfectly well. 

At the present time she has slight nausea but with no 
regularity. It may come at any time, morning, noon or 
night. She has noticed that micturition has increased in 
frequency and the breasts have occasionally a prickling 
sensation in them. Her next period is due in a very few 
days. I warned her about the importance of keeping quiet 
and doing nothing more than she absolutely had to do at 
this time in the light of the history of the first pregnancy. 

February 4. She telephones that this afternoon about 
three o'clock she noticed that she had the slightest show 
which she thought was blood but had no pain. She im- 
mediately went to bed. What she showed to me was a 
leucorrheal stain with not the slightest tinge of blood in it 
but she said this was exactly the way she started in in her 
first pregnancy and because she was so apprehensive I 



28 CASE HISTORIES IN OBSTETRICS. 

agreed with her that she must stay in bed until this period 
was over. I sent a nurse out at once. 

February 7 th at half -past three a.m. patient was awakened 
by passing a large clot and there was bright red flow. In a 
very few moments she stained through one pad. Had ab- 
solutely no pain. In ten minutes this sudden gush of blood 
stopped. Pulse 68. From four until eight, when the pads 
were again changed, she had soaked through entirely the 
first pad and part of the second. At eight o'clock she passed 
a small clot and when I saw her again at eleven there was 
still a slight amount of bright red flowing. In the afternoon 
the flow became less bright and less in amount. She has no 
temperature and pulse is ']2, 

February 9. Yesterday there was very slight amount of 
flow, not staining through one napkin. This afternoon the 
nurse telephoned that the patient passed without pain some- 
thing that looked like a membrane. The specimen was evi- 
dently a cast of the uterus. It was put in alcohol and 
taken at once to a pathologist. 

Vaginal Examination : — The uterus corresponds in size 
to a two months pregnancy. The fundus of the uterus is 
anterior. Nothing on the left is palpable. On the right 
running from the side of the uterus forward to the right 
inguinal canal is a small round tube which gives the im- 
pression that it might be a round ligament put on stretch 
following her Alexander operation. I could not make out 
anything on either side of the pelvis but the fact that she 
had passed this membranous cast made me suspicious of an 
extra-uterine pregnancy. After the cast was passed there 
was absolutely no flow. I asked for a consultation with the 
surgeon who had done the Alexander operation because I 
knew that if she were to have another operation she would 
want him to operate. At this time he was out of town 
for three or four days. The only treatment now indicated 
was to keep the patient quiet in bed and await develop- 
ments. 

February 12. Report from the pathologist says that the 
specimen sent consisted of a membranous sheet from the 
uterus. ** Microscopic examination showed it to be com- 



DIAGNOSIS OF PREGNANCY. 29 

posed of decidual cells and nowhere was there any chorionic 
villi. Diagnosis, decidua of pregnancy, extra-uterine (?)." 

February 14. There has been no flowing and no pain 
since the cast was passed. The consultant saw the patient 
to-day. His questioning brought out no new points. He 
found the uterus to be in third degree of retroversion, and he 
very readily replaced it. At this time he noticed that there 
was a band running off from the uterus on the left side 
as well as from the right. He could find nothing abnormal 
outside the uterus. He considered that she was two months 
advanced in a normal pregnancy. On talking the situation 
over we both brought forward the possibility that she might 
have a bicornate uterus and that one side had miscarried 
while in the other pregnancy was advancing. 

February 16. There has been no flow now for one week. 
She is to get up out of bed for an hour to-day and very 
slowly to get about again. On February 24th she went 
downstairs with no untoward effect. 

February 28. Examination to-day shows the uterus in 
third degree retroversion. Cervix is close to the symphysis. 
Nothing felt on the sides. There is no tenderness in the 
pelvis, except when I attempted to replace the uterus. 
Uterus is still larger than normal though there is no in- 
crease in size since my last examination. She is going about 
doing more and more. Her general condition is satisfactory. 

March 2. Patient telephones to-night that she is having a 
very slight flow, that she had sent for the nurse and that she 
had gone to bed of her own accord. There is absolutely no 
pain and no clots have been passed. 

March 3. Absolutely comfortable. No pain. Flow 
which came last evening was very dark in color. Now has 
become bright red without any pain and without clots. She 
feels as if she were having a menstrual period as she is having 
pain in her hips which she says she usually does have at the 
beginning of her menstruation. To-day she stained through 
two napkins. 

'March 4. Flow becomes distinctly less. At no time has 
she had any pain. 

March 6. Flow- stopped yesterday. To-day she got up 



30 CASE HISTORIES IN OBSTETRICS. 

and there is no flow and no pain. She was told to go about 
her house and gradually to get back to her regular routine. 

March 22. Vaginal Examination: — There is no blue- 
ness of the introitus. Cervix slightly softened. Uterus in 
third degree retroversion. It is but very slightly enlarged. 
It can in no way be regarded as the size of a three months 
pregnancy. There is nothing palpable on either side. 

As she is certain that she is three months pregnant or not 
at all, I told her to get up and go around as if she were not 
pregnant. There is a possibility that she may have some 
retained products of conception but if she does not flow 
irregularly I advised against her being curetted. If she be- 
gan to flow irregularly in any way I told her that she would 
have to be curetted. 

April 6. She began to menstruate shortly after my ex- 
amination on March 22nd. A normal period, as far as she 
can determine. Comes in to-day in order to have the 
uterus replaced and to try wearing a pessary. Cervix is 
felt just below the symphysis. Uterus is in third degree 
retroversion and freely movable. By bimanual manipu- 
lation the uterus was raised into normal position. A pessary 
was placed and this held the uterus in excellent position. 
Uterus is normal in size. 

June 14. Since last note the patient has had two periods. 
As far as she can determine absolutely normal in character. 
The pessary is comfortable. She has no backache and no 
bearing down sensations. The uterus is normal in size and 
position. There is no vaginal discharge. There are no ab- 
rasions in the vagina. Pessary cleaned and replaced. 



The patient, since this history was written, became preg- 
nant while wearing the pessary. The pessary was removed 
when she was three and a half months advanced. Her 
pregnancy was normal in all respects and she delivered her- 
self, after a short labor, of an eight and three-quarters pound 
baby. 



DIAGNOSIS OF PREGNANCY. 3I 

Summary of Diagnosis of Pregnancy. 

The four preceding cases are fairly typical ones showing 
some of the problems that may arise in the diagnosis of 
pregnancy. 

The history that a patient gives you is always of question- 
able value depending upon her ability and willingness to 
give even an approximately correct statement of her 
symptoms. 

The patient's menstrual history from the onset of this 
phenomenon is important and in every case must be entered 
into carefully. Slight irregularities in women who have pre- 
viously always been regular are to be kept in mind and may 
be the first suggestion to put the diagnosis of extra-uterine 
pregnancy before the physician. A cessation of menstru- 
ation is the first of the presumptive signs of pregnancy and 
in all of these cases it was present. Slight staining each 
month during the first few months of pregnancy is not so 
rare as to be regarded as a sign against pregnancy. It must, 
however, be regarded as abnormal and the physician must be 
on his guard for an error in his diagnosis of a normal preg- 
nancy. 

The second of these presumptive signs is nausea and 
vomiting. This is so irregular in all its happenings, that I 
have come to disregard it almost entirely. In Case 3 it was 
present, yet the patient was not pregnant. In the other 
cases it was present at very variable times. One must not 
get the idea that the nausea and vomiting of pregnancy 
comes always in the morning. In a majority of cases it 
probably will come then but in not a small minority it ap- 
pears at any part of the day except when the patient is 
sleeping. 

The third sign is the change in the number of times the 
patient desires to micturate. Especially suggestive is the 
getting up at night when previously she has never had to 
do so. The pressure of the enlarging uterus on the bladder 
is the cause; the amount of urine secreted is not necessarily 
increased. I am inclined to think that a primigravida 
notices this change more often than does a multigravida. 

The fourth sign is the alterations in the breasts. In a 



32 CASE HISTORIES IN OBSTETRICS. 

primigravida these changes are of much greater value than 
in a woman who has previously borne children. The in- 
creased firmness, the increase of size, the increase in width 
and depth of color of the areola all may be noticed by the 
patient by the fourth week in pregnancy. But the amount 
of change is most variable and not such that a positive 
diagnosis can be made. The veins are apt to stand out very 
prominently as in Case i. Tingling or prickling sensations 
in the breasts, especially at the time of the first passed period, 
are very suggestive. When an illegitimate pregnancy is 
suspected one can oftentimes obtain an admission of these 
sensations because the patient does not connect the breasts 
with her pregnancy. A certain small percentage of women 
have indefinite sensations in their breasts at each menstrual 
wave and in these women manifestly this sign becomes of 
less value. 

The fifth sign, changes in the mental condition of the 
patient, is, when present, of much aid, especially when the 
patient is known to you beforehand. Patients may show 
irritability, depression, or exhilaration. As they are in one 
pregnancy they are very apt to be in the following. Whether 
to regard the cravings, the perverted appetites, that come so 
often in pregnancy as a mental or digestive phenomenon is 
uncertain. This condition was definitely present in Case 
2. In Case i the odor of tobacco smoke nauseated the 
patient and it had never done so before. These signs all 
go to show how unstable a woman may be during a preg- 
nancy. They are all important to note in making a diagnosis 
of pregnancy. Stress is not to be put upon them because 
they all come from the patient and if she has anything to 
hide they become of no value. If the patient is anxious for 
children, as in Case 3, her desires color her story and make 
it also of no value. 

These presumptive or better called subjective signs of 
pregnancy are on the whole of little real value in making an 
absolute diagnosis of pregnancy and should never be relied 
upon. When the patient is an intelligent woman, as she was 
in Case 2, and has nothing to hide, nothing to desire, the 
history obtained is often of great help. 



DIAGNOSIS OF PREGNANCY. 33 

The objective or probable signs of pregnancy are de- 
termined by the physician and it is upon these in the early 
months that the diagnosis must be based. 

The first is the enlargement of the uterus as determined 
by vaginal examination. How early a physician can make 
a diagnosis of an enlarged uterus depends entirely upon his 
ability and whether the patient has a thin relaxed abdominal 
wall. 

From the sixth to the eighth week a careful examination 
will usually give Hegar's sign, i.e., the softening between 
the tissues of the cervix and the fundus combined with the 
ballooning out of the sides of the uterus as shown in the 
lateral culs-de-sac. Combined with the enlargement of the 
uterus is the softening of the cervix. This softening when 
there is no endocervicitis present is very characteristic, 
especially in a primigravida. It is less marked in a multi- 
gravida. In order to rule out any endocervicitis the cervix 
must be inspected. Hegar's sign was definitely made out in 
two of these cases and the softening of the cervix was noted. 

The second objective sign is the change in the breast tis- 
sue. Before one can appreciate the changes which take 
place in a pregnancy one must know the breast, its shape, its 
consistency, the areola, of the non-pregnant woman. In 
Case I the breasts were typical and combined with the 
other signs made the diagnosis relatively simple. In the 
early weeks of pregnancy it is very seldom that secretion 
can be expressed from the nipples in a primigravida. In a 
multigravida this sign is of little or no value. 

These two signs, the enlarged uterus and the changes in 
the breasts, are the earliest signs upon which a diagnosis can 
be based. The enlargement of the abdomen, and the inter- 
mittent contractions of the uterus, are not apparent in the 
first two months of pregnancy. The increased vaginal 
secretion may occur but it is of no diagnostic import and the 
same may be said of the blueness of the introitus. 

Abderhalden's serum reaction for the diagnosis of preg- 
nancy may eventually be so simplified as to be more available 
than it is at the present time. Excellent results from many 
writers are being reported, but for the general practitioner, 



34 CASE HISTORIES IN OBSTETRICS. 

unless he has access to a well equipped laboratory, it is out 
of the question. Moreover there are relatively few cases 
where it is essential that a diagnosis be made at once, or 
where it is not possible to wait a few weeks so that the diag- 
nosis can be certain. Extra-uterine pregnancy demands an 
early and correct diagnosis and if by this reaction the pres- 
ence or absence of a pregnancy can be accurately determined, 
then the treatment of the case becomes much simplified. 

The interpretation of the positive signs of pregnancy all 
depends upon the training and ability of the physician. 
There is no more humiliating mistake than to err in a diag- 
nosis of pregnancy. The grouping of the subjective and 
objective signs must be done without prejudice remember- 
ing that no matter in what station of life the patient is, 
pregnancy is possible. 



SECTION II. 
MISCARRIAGE. 

Case 5. Inevitable Abortion. Patient is seen for the 
first time June 13. Her last menstruation was April 23. 
It was a normal period lasting five days. She skipped her 
May period. The March period was perfectly normal. 
She considers herself in the second month of her second 
pregnancy. This morning on getting out of bed she noticed 
that there was a slight pinkish show. There has been no 
pain. She is a very active athletic woman playing much 
tennis and golf. Yesterday she played several sets of tennis 
and got very tired. She has fainted once since she was 
pregnant, but as this is a very common thing for her she 
thought nothing of it. Last night she had a sharp pain in 
her right side which lasted a few moments and then passed 
off. She says she also had this pain three days ago. She 
has not vomited, but is nauseated. Her pulse is 62 and 
temperature normal. 

Abdominal examination shows scaphoid abdomen. Tym- 
panitic throughout. Slight tenderness on deep pressure on 
the right side low down in the pelvis. No spasm present. 
Otherwise the abdominal examination is negative. 

Vaginal Examination: — On the napkin there is slight 
stain, pink in color. The cervix is soft, not dilated. The 
fundus of the uterus is drawn slightly to the right side. It 
is slightly enlarged. There is a suggestion of Hegar's sign. 
There is nothing in the posterior cul-de-sac. Nothing ab- 
normal is felt on the sides. There is no tenderness in the 
pelvis. While talking with her she said she began to feel 
slight pains as if she were going to menstruate. 

Diagnosis: Threatened miscarriage. 

Treatment: Bed, absolutely; simple diet, morphia and a 
nurse. She telephones at one p.m. that she has begun to 
flow profusely. I w^ent to her at once and learned that just 

35 



36 CASE HISTORIES IN OBSTETRICS. 

after she telephoned she had two severe pains and then 
passed something by the vagina. Her first impulse was to 
burn it up which she did. She now is flowing slightly, of a 
bright red color and the blood clots very quickly. Her 
pulse is 80. At no time since she passed the mass has she 
had any pains. During the afternoon up to six o'clock she 
stained through two napkins with bright red blood. She 
was having no pain. Pulse 70. Temperature 99°. 

June 14. From ten o'clock last night until eight this 
morning there was no flow. She slept all night. Pulse 70, 
temperature 98.6°. At noon she passed a small clot and be- 
gan to flow so that she stained through one napkin in two 
hours. During the afternoon the nurse reports that she is 
having a few indefinite pains and passed a clot of blood 
about two inches long by one inch broad. Diagnosis now 
changed to an incomplete miscarriage and I advised that she 
be curetted in the morning. 

June 15. She was prepared and etherized. A careful 
pelvic examination revealed nothing on the sides. The 
uterus is enlarged to the size of a two months pregnancy 
and is soft. The external os is soft and admits one finger. 
The cervix was dilated carefully by a Goodell dilator and a 
large sized blunt curette then passed into the uterus. Much 
blood clot and considerable decidual tissue were removed. 
The uterus was then curetted carefully and lightly with a 
sharp small curette, and the cavity of the uterus wiped out 
with gauze sponge soaked in 70% alcohol. The uterus shut 
down at once and there was no bleeding. A sterile pad was 
put on and patient put back in bed. 

June 18. She has made an excellent recovery. There 
now is but a very slight discharge present. Temperature 
normal. Pulse 62. 

The patient got up out of bed on the sixth day after curet- 
tage and two weeks later examination showed the uterus to 
be normal in size and position. Nothing felt on the sides. 
No tenderness anywhere in the pelvis. There is no vaginal 
discharge. Menstruation returned in August and since that 
time has been regular and with the same characteristics as 
before the curettage. 



MISCARRIAGE. 37 

Case 6. Threatened Abortion. November 5. A tele- 
phone message was received from a physician saying that he 
had just seen a patient of mine who was miscarrying. He 
said she was at a neighbor's house when without warning she 
had a sudden gush of blood from the vagina and was flooded. 

The patient was out of town and as soon as possible I saw 
her. I found her in bed and obtained from her the follow- 
ing story: — She had walked over from her home, a distance 
of only about a hundred yards, when without warning she 
felt herself flooded. She at once was put to bed at her 
neighbor's. She now is having pains every ten minutes, not 
severe, a little more marked than at her menstrual periods. 
She was given at once an eighth of morphia subcutaneously. 
Her underclothes were covered with blood. Shortly after 
she was put to bed the flowing decreased in amount and 
when I arrived three hours after the first gush I found no 
flowing. Her last menstruation, which was on August i8th, 
was normal in amount and in character. She flows every 
twenty-six days and she has never skipped a period except 
when she is pregnant. Her first baby was born twenty 
months ago. Her pulse was 70 and temperature 98.4°. 
The pains grew less marked but at the end of an hour were 
still present and I repeated the morphia. From then to six 
o'clock she stained through one napkin. At half past five 
she was not having any pains. She insisted, not unreason- 
ably, on going home. She was given another eighth of 
morphia by mouth and at six o'clock was carried across to 
her own home. Because of the expense and because she 
rather wanted to miscarry she refused to have a nurse but 
she did agree to stay in bed until I saw her the next day. 
Telephone message from her husband at eight p.m. saying 
there was but slight flow and no clots had appeared. He 
was then told to give his wife another tablet of morphia 
gr. I /8 at ten and to repeat it at two in the morning. 

November 6. From ten last night until seven this morn- 
ing she used but one pad. On this pad she found one dark- 
red clot the size of a hen's egg. She slept all night and did 
not have the morphia at two. This morning she was hav- 
ing a few fleeting pains and was told to take a tablet of 



38 CASE HISTORIES IN OBSTETRICS. 

morphia every four hours. The patient telephones in the 
evening saying that she had used but one pad and that was 
not soaked through. Has had no pains. Against my order 
she got up three times during the day to go to the bathroom. 

November 7. Husband telephones this evening that his 
wife will not stay in bed, partly, because she does not care 
whether she miscarries and partly because of trouble with 
her servants; that she now is not flowing and has no pain. 
Morphia which she had been having every four hours was 
now stopped. 

November 8. This morning husband telephones that she 
was "flowing badly with clots" and that she was having 
pains "every little while." He frankly said it was impossible 
to keep her in bed. I decided then from this story to curette 
her in the afternoon. 

Vaginal examination this afternoon showed a uterus 
symmetrically enlarged to the size of a grape-fruit. Os 
uteri not dilated and cervix no softer than normal, no blood 
on the examining finger. No tenderness on the sides. Tem- 
perature normal and pulse 68. The patient said there had 
been no flowing since morning. I flatly refused to curette 
her and left the nurse whom I took out with me, on the case, 
with orders to keep the patient absolutely in bed. 

November 10. There has been no flowing now for forty- 
eight hours and the patient has stayed in bed up to this 
evening. The nurse has had fair control over her but she 
leaves to-night. 

November 14. There has been no flowing and she has had 
no pains since the last note. She has consented to stay in 
bed for breakfast and not to come downstairs until lunch 
time for one week. 

November 28. Telephone to-day from the husband say- 
ing his wife had been flowing for two days but would not 
say anything about it to me. I saw her this afternoon and 
she looks well. Pulse 70 and temperature normal. She 
says a week ago she had severe intermittent pain which 
lasted for two hours and was accompanied by flowing, bright 
red in color. The flowing ceased in three or four hours and 
she said nothing about it. Until yesterday she had no 



MISCARRIAGE. 39 

more flowing. It is impossible to find out accurately how 
much flow she had yesterday. She had no pain. To-day 
she is flowing less she says than yesterday. The pad which 
she has had on for four or five hours is well soaked through 
with bright red stain. 

Vaginal examination to-day shows the os uteri tight. 
The uterus is distinctly larger than at the previous exami- 
nation. I told her I would not curette her, that any such 
procedure would be nothing short of criminal arid that if 
she became seriously sick the blame was hers, not mine, and 
I also wrote to the husband telling him where the respon- 
sibility lay. 

December 5. The husband reports to-day at the office 
that there has been no flowing since the last examination. 
He says his wife is feeling much better and he thinks she is 
trying to keep very quiet. I asked him whether intercourse 
could be the cause of this continued bleeding but he denied 
it as had the wife some weeks previously. 

From now on her pregnancy advanced without incident 
and she was delivered of a healthy but small baby three 
weeks ahead of the reckoned date. 



40 CASE HISTORIES IN OBSTETRICS. 

Case 7. Retroverted Incarcerated Pregnant Uterus. 
Blighted Ovum. Patient comes to the office February 13th. 
She has always been perfectly well. Her first child by her 
first husband was born thirteen years ago. Normal delivery. 
Last normal menstruation was December 12. It lasted 
three to four days and was normal in all its characteristics. 
The present pregnancy is not remarkable except that she is 
very constipated. Bowels not moving oftener than once in 
four days. She has taken castor oil occasionally for the 
past two weeks. She drinks but one glass of water a day. 
Is doing the usual things which she does when she is not 
pregnant. Her bowels now had not moved for three days. 
I told her she should be examined at once but she refused. 
I went over with her the care that she should take of herself 
during her pregnancy, and told her this evening when she 
was ready to retire to take an oil enema of four ounces, to 
retain this over night, also to take as soon as she got home 
a half teaspoonful of the fluid extract of cascara sagrada and 
to repeat this at bedtime. In the morning she was to take 
a large suds enema while lying on her left side. If she 
did not get a good result from this treatment I told her to 
report at once to me. As a routine I advised her to take 
thirty drops of cascara three times a day; if this proved to 
be too much to reduce it. It was made clear to her that 
she must have one movement each day and if she did not 
have it by noontime she was to take an enema. Her food 
was regulated and the importance of drinking at least ten 
glasses of fluid was impressed upon her. 

February 23. I heard nothing from her until to-day when 
her husband telephones that she was passing blood by the 
vagina. I saw her at once and got from her the following 
story : — For the first four days after she was at the office 
with the aid of enemata and cascara she obtained good move- 
ments. From then until the 21st of February she had but 
one movement, and she excused her carelessness because of 
her many social engagements. On the 21st of February 
about noon she had a large hard movement with severe 
pain. She passed some blood, which she said she thought 
came from the rectum. On the 22nd she had another very 



MISCARRIAGE. 4I 

constipated movement and in the afternoon passed a clot 
without pain. This clot she said came from the vagina. 
Since then until this morning she has seen no blood. 

Vaginal Examination: — The rectum is packed with 
hard ball-like feces, extending upward as far as one could 
reach. Satisfactory pelvic examination, on account of this 
packed condition of the rectum, is impossible. She at once 
took an oil enema, followed four hours later by a glycerine 
enema of four ounces with water two ounces. Much large, 
hard, ball-like feces was passed. Another oil enema was 
carried over night and another glycerine and water enema 
ordered for the morning. She was to continue her cascara 
as before ordered. 

February 24. This morning she had another large move- 
ment. 

Vaginal Examination: — No blueness of the vagina. 
Cervix is not softened. Os uteri not dilated. Uterus is in 
third degree retroversion and slightly enlarged. Non-tender. 
Nothing felt on the sides. No blood in the vagina. She is 
to stay in bed to-day, getting up only to go to the bathroom. 

February 25. This morning she found a slight dark red 
stain on her night dress. Bowels are now moving regularly 
and she is not constipated. 

February 26. There is no staining and she is perfectly 
comfortable. Still in bed. 

February 28. Last night she passed a small amount of 
dark blood and she notices that the stain is especially marked 
when she has a movement. There is no increase in mic- 
turition. Bowels are now constipated. She is flowing very 
slightly. Breasts are absolutely negative. Areola is not 
darkened. Glands of Montgomery are not enlarged. Is to 
report any increase in flowing or any pain. A nurse was 
sent out to-day, and the patient is to stay in bed absolutely. 
Bowels are to be moved by cascara with the aid of enemata. 

March i. She has had no pains and no flowing. Bowels 
move by enema every morning. Is to stay in bed another 
forty-eight hours before any attempt to replace the uterus 
is made. She is having no pains. 

March 3. She began bleeding this morning at one. At 



42 CASE HISTORIES IN OBSTETRICS. 

three she began having pains once an hour with a bright red 
flow. 

Vaginal Examination: — Os uteri dilated one finger and 
the cervix very soft. 

Diagnosis : Inevitable miscarriage. 

Treatment: In Sims' position and with a large Sims' spec- 
ulum I packed the cervical canal with sterile gauze and also 
the vagina under aseptic precautions. 

By noon the pains were coming every fifteen minutes and 
in the evening the pains became very hard and came with 
increasing severity until one o'clock, the morning of the 
fourth, when they ceased entirely. From then on she slept. 

March 4. This morning the packing was taken out and 
in the vagina was found an intact ovum. The ovum is 
small, one and a half inches long by one inch broad. She 
could not in any way be regarded as three months along in 
her pregnancy. The probablity is that the ovum was a 
^'blighted " one and that the first bleeding was due to Nature's 
attempt at that time to throw it off. The patient being kept 
quiet, the uterus did not expel it. 

The patient now made an absolutely normal convalescence 
and got up on the sixth day. Examination on the eighth 
day showed no flowing. The uterus is in marked retro- 
version. There is no tenderness present in the pelvis and 
nothing felt on either side. All attempts to replace the 
uterus were absolutely unsuccessful. I then advised that 
she have ether and an attempt be made to replace the uterus. 

March 13. The patient etherized this morning. After 
much manipulation and with traction on the cervix with a 
double hook, the uterus was raised into an anterior position. 
In this position it was seen that the fundus was drawn to 
the patient's left and the moment the hand on the abdomen 
was removed the fundus fell backward. It was again 
brought up into position and after several pessaries were 
tried one was obtained which seemed to hold the uterus in 
good position. 

March 23. The uterus to-day is found in first degree 
retroversion and the fundus is drawn to the left. A larger 
pessary with a sharper curve was put in and the uterus 



MISCARRIAGE. 43 

held in position. Bowels are moving regularly with the aid 
of cascara. 

April 8. Menstruation appeared March 24th and lasted 
through the 28th. Character no different from previous 
periods. She complains of feeling a pressure from the 
pessary low down in the vagina. Examination shows the 
uterus in second degree retroversion. In the posterior cul- 
de-sac is a very tender spot. Attempt to replace the uterus 
causes the patient pain. There is no break in the vaginal 
mucous membrane. Pessary left out. I then advised her 
to have a suspension of the uterus done with freeing of the 
probable adhesions. Up to the present time, she has not 
seen fit to have any operation performed. 

Note : — Since the above history was written, this patient 
had a suspension of the uterus done. Later she again be- 
came pregnant. I did not have charge of her during this 
pregnancy, but I was called upon to deliver her. She had 
a normal delivery without any vaginal examinations. Soon 
after delivery she said that her right leg pained her. I did 
not give this much thought for it was where ergot had been 
given her intramuscularly. Temperature that night 100°, 
pulse 90. The next day the pain was much greater. Tem- 
perature in the evening 101° and pulse 100. I looked over 
her leg carefully and found definite edema of the leg and 
ankle. Distinct tenderness in the groin and lower leg. I 
went into the history of her pregnancy and found that for 
ten days before she was delivered she had had in her right 
leg slight edema and the pain had been so great that it had 
kept her upstairs. Her leg had been bandaged. Her tem- 
perature had not been taken. My diagnosis was an ante- 
partum phlebitis. Her temperature gradually rose until it 
reached 102.8° with a pulse of 120 on the sixth day after 
her delivery. From then on her temperature fluctuated 
from 100° in the morning to 101° at night for five days more 
when it gradually dropped to normal on the seventeenth day. 
During this entire febrile time there was nothing on physi- 
cal examination to account for this temperature except the 
phlebitis. After the temperature had been normal for one 
week she was allowed to get up. 



44 CASE HISTORIES IN OBSTETRICS. 

Case 8. Automobile Miscarriage. A telephone mes- 
sage was received from a physician September 20th, saying 
his wife was having a threatened miscarriage, ten weeks along 
in her fourth pregnancy, and that he wanted me to see her at 
once. I went to her and obtained the following history : — 
Her last menstruation was from July 1st to 5th. Normal in 
every respect. There was no August or September period. 
Pregnancy advanced without incident until September i6th, 
when she went for an automobile ride of some fifty miles. 
The chauffeur was careless and the roads were very rough. 
September 17th she was up and about the house and in the 
afternoon noticed that there was a very slight stain on her 
underclothes. Dark brown in color. She had no pain and 
there were no clots. She told her husband nothing about it. 
On the 1 8th about two o'clock in the morning she had very 
slight irregular pains in the back and lower abdomen, and 
had again a slight stain of dark blood. Her husband gave her 
at once one-eighth grain of morphia and repeated it in two 
hours. On the i8th she stayed in bed all day with but 
very slight flowing, dark red in color, staining one pad dur- 
ing the day. An occasional small clot was passed. In the 
evening the flowing was a little brighter in color. On the 
19th she got up and went downstairs and did a few things 
about the house. On the afternoon of the 19th there was a 
little more flowing and she had a few cramp-like pains at 
irregular intervals. She did not go to bed until the even- 
ing of the 19th. From then on pains became harder and 
harder and early in the morning of the 20th she passed 
some " membranous tissue." Her husband was by neces- 
sity away from home from the evening of the 19th until 
seven in the evening of the 20th. He then found her flow- 
ing profusely, bright red blood; she stained through one 
pad in half an hour. He made a vaginal examination and 
found the cervix plugged with a soft mass. When I saw 
her there was but little active flowing. She was having a 
few indefinite, irregular pains. Temperature was normal 
and pulse 80. Vaginal examination confirmed his findings. 

Diagnosis: Inevitable miscarriage, due to an automobile 
ride. 



MISCARRIAGE. 45 

Treatment: Curettage at once. She was etherized and 
then prepared. The uterus was found to be about the 
size of a three months pregnancy. Cervix showed a bilateral 
tear, admitted a finger and was very soft. Nothing abnormal 
felt on either side. A large-sized blunt curette was passed 
into the uterus and a mass of old blood clot and decidua 
was removed. Even after she was curetted she continued 
to bleed rapidly and a finger was then introduced into the 
uterus with counter pressure on the fundus, and at the 
fundus of the uterus was found a mass of decidual tissue. 
This was removed by the finger. Uterus was wiped out 
with sterile gauze soaked in 70% alcohol. The uterus then 
contracted down hard, and there was no bleeding. She was 
put back to bed with a pulse of 100, in excellent condition. 
She made an absolutely normal convalescence; she was out 
of bed on the eighth day and gradually resumed her usual 
duties. 

Summary of Miscarriage. 

One of the first points to decide in the question of a threat- 
ening miscarriage is whether the patient, in order to avoid a 
complete one, can and will do what the physician in charge 
thinks is necessary to be done. In Case 5 the patient was 
anxious and willing to do everything, as she was in Case 4, 
but in Case 6 the patient was neither willing nor able to do 
what was indicated. If she is unwilling, there are two 
means of dealing with her, either to withdraw at once from 
the case, letting it be clearly understood why you do so, or 
if that is inadvisable for any reason then to write to the 
husband clearly and forcibly of the risk the patient is taking. 
Put the responsibility where it clearly belongs and then you 
will have nothing with which to reproach yourself if the 
patient becomes seriously ill. 

The question of examining a threatened abortion is not 
readily settled. Absolute rest both of body and mind is the 
first point to be sought. A vaginal examination unquestion- 
ably stirs up many women a great deal; it is more marked 
in a primigravida than in a multigravida. If there is the 
slightest suggestion in the history obtained of an extra- 
uterine pregnancy the patient must be examined at once. 



46 CASE HISTORIES IN OBSTETRICS. 

In Case 5 the sharp right-sided pain was suggestive. In 
Case 4 the passing of the cast of the uterus was most sus- 
picious and called for a careful pelvic examination. The 
amount of flowing is no contra-indication for such an ex- 
amination, no matter how much the patient may object. 
She must be examined and an extra-uterine pregnancy ruled 
out as certainly as is possible. 

In making a vaginal examination the patient should be in 
the dorsal position with her legs flexed, well on the edge of 
the bed, clothes off and properly draped, avoiding all un- 
necessary exposure, but the introitus must be in plain view. 
The vulva must be washed off with soap and water and then 
wiped off with boiled water. A sterile glove must be used 
and in inserting the examining fingers care must be taken 
not to touch either side but go directly into the vagina. 
The size and position of the uterus, its consistency, the 
condition of the os uteri, the presence of a mass on one side 
of the uterus or the other all must be carefully determined. 
If there is flowing alone, without pain and no history of 
pain in the lower abdomen I usually do not examine the 
patient at once. If the patient is willing to have a nurse, 
go to bed and do everything that is possible to avoid a mis- 
carriage then do not examine. The point to be determined 
is, Shall we do more harm to the already damaged uterine 
contents by an examination or shall we gain some informa- 
tion which will lead us to treat this individual case more 
intelligently? By delaying your examination you may keep 
the patient in bed a few days longer; by examining at once 
you may change a threatening into an inevitable miscarriage. 
Indiscriminate examinations undoubtedly do harm; de- 
layed examinations when the case is under competent super- 
vision are not harmful but each individual case must be 
settled from the history and from the signs. 

Rest, as I have already said, is the prime requisite in the 
treatment of threatened abortion. The patient must go to 
bed and stay there. She must use the bed-pan and she 
must lie as quietly as possible while she is in bed. No 
sitting up and no sudden turning over is to be allowed. 
Explain to the patient what is happening to the uterine 



MISCARRIAGE. 47 

contents and she will help you more intelligently. If the 
patient is having pain, morphia is the only drug indicated. 
How large a dose to give will depend entirely upon the 
amount of pain, upon the size of the patient and her indi- 
vidual susceptibility to morphia. Case 3 showed a definite 
idiosyncracy to morphia. Three one-eighth grain doses 
made her delirious. Whenever you give morphia find out 
whether the patient has this idiosyncracy for it and if she 
has, go by her history. The first dose of morphia usually 
should be given subcutaneously. Thereafter it can be 
given by mouth every four hours or oftener if necessary. 
Due care must be taken to avoid any excessive use, thereby 
causing poisoning. After the patient has been kept under 
morphia for twenty-four hours and she has had no pain the 
interval can be increased to every eight hours and then 
gradually to longer intervals until it is entirely dropped. 
If the patient is not in pain and is flowing but slightly there 
usually is no indication to give morphia; rest in bed will be 
sufficient, but if she is apprehensive and unable to keep 
quiet choose some drug that will give her repose. 

After a patient has had a threatened miscarriage the 
question when to allow her up out of bed is of considerable 
importance. She ought to be in bed at least one week after 
all morphia has been stopped and there has been no flow. 
Then she should get up very slowly, first around her own 
room and then on her floor and by the end of the second 
week, if no untoward symptoms have occurred, it will prob- 
ably be safe to let her go over the stairs. A patient who 
has had a threatened miscarriage and who has quieted 
down must keep relatively quiet the remainder of her preg- 
nancy. At the times which would correspond to menstrual 
periods were she not pregnant, she should be at home abso- 
lutely quiet, not necessarily in bed unless the uterus shows 
itself to be irritable either by a few pains or by marked con- 
tractions. If such a condition arises then she ought to go 
to bed until this period is over and have small doses of 
morphia. 

It is surprising the amount of flowing that can occur 
and the pregnancy continue in spite of it to a successful 



48 CASE HISTORIES IN OBSTETRICS. 

outcome. This was well shown in Case 6. She flowed 
at intervals for three weeks. The first time it was very 
marked. This patient had not only flowing but she had 
pains and the first diagnosis was an inevitable abortion, but 
examination showed there was no dilatation of the os uteri 
and the size of the uterus corresponded to the length of 
her pregnancy. As the case progressed it was seen that 
the uterus was enlarging and corresponding to the preg- 
nancy. I am inclined to think that physicians as a whole 
are a little too quick to curette a threatening miscarriage. 
There is no question that if we delay and then have 
to curette we lose a certain number of days and no good 
comes to the patient. If the patient continues to flow and 
there is no increase in the size of the uterus there is no 
question but that a curettage is indicated because she must 
have some products of conception retained. On the other 
hand, as in Case 4, where the membrane was passed, or in 
Case 7, where an intact ovum was passed and the flowing 
immediately stopped, the uterus coming down to normal 
size, there is no indication to curette. When menstruation 
becomes established at once and is thereafter perfectly 
regular with the usual characteristics, curettage is entirely 
unnecessary, but if there is a constant or irregular dribble of 
blood-stained discharge, curettage must be done. 

In making preparations for a curettage, the patient should 
be shaved or clipped closely. She is then etherized and 
placed on the edge of the bed or on the table. In the home 
the bed is usually used. There must be good light. When 
etherized, the vulva is scrubbed thoroughly with soap and 
water, washed off with sterile water or corrosive sublimate 
solution 1-3000 finishing with 70% alcohol. The vagina is 
then thoroughly wiped out also with alcohol. The legs are 
held either by the nurse or by the leg holder. If the ordi- 
nary Robb leg holder is used care must be taken to avoid 
pressure on the patient's neck and in the popliteal spaces, by 
placing towels around the legs and neck. I have seen more 
than one patient bitterly complain of the pain from this 
pressure. If the leg holder is not at hand a twisted sheet 
can be used with perfect satisfaction. The instruments for 



MISCARRIAGE. 49 

curettage layout are as follows: weighted vaginal speculum, 
French hook, Goodell dilator, large blunt curette, small 
sharp curette, long dressing forceps, ovum forceps and a 
pair of scissors. Gloves, sterile gauze and half a dozen 
sterile towels must be at hand. Besides these instruments a 
basin of sterile water or corrosive sublimate 1-3000 and a 
basin of 70% alcohol must be ready. Before one proceeds to 
curette a patient a careful pelvic examination should always 
be made with the patient under ether in order to rule out 
any complicating condition outside the uterus. The oper- 
ating field is covered with sterile towels. The vaginal 
speculum is put in place and the French hook grasps the 
anterior lip of the cervix. (A single hook should never be 
used, for in pregnancy the cervix is so soft that the hook 
pulls out.) If dilatation is sufficient so that the large blunt 
curette can be immediately inserted into the uterus there is 
no indication to use the dilator, but if it is not sufficiently 
dilated then the dilator must be used. It must be used 
carefully and slowly with its branches placed in turn in dif- 
ferent parts of the cervical ring. Dilatation is not to be ac- 
complished with the dilator in one place. But rarely will the 
Hanks dilators be necessary. After the large blunt curette 
is used and the detritus is removed, then with the ovum for- 
ceps some of the remaining bits can be taken out. Whether 
one uses for a final curettement a small sharp curette depends 
entirely upon whether the operator believes in its use. In a 
pregnant uterus a few weeks along there is no reason why it 
should not be used if it is used carefully. No matter what 
the instrument is, if it is used carelessly damage will come; 
but with a small sharp curette much of the decidua can be 
removed and no damage be done. After you consider the 
uterus empty, a piece of gauze, so folded that no shreds will 
come free, is passed into the uterus, by means of a long pair 
of dressing forceps, turned gently about and withdrawn. If 
troublesome bleeding persists and occasionally it is very 
troublesome and severe, then put a finger in the uterus and 
sweep it around while the other hand is above the pubes 
on the fundus of the uterus giving you counter pres- 
sure. Usually in such cases one will find a small piece 



50 CASE HISTORIES IN OBSTETRICS. 

of decldua attached to the fundus as was found in Case 8 
and this is readily removed by the finger. Do not persist in 
trying to empty the uterus absolutely of all the decidual 
shreds. If one keeps curetting, some decidua and then 
the uterine muscle will come away. Of this there is 
no question, and if the operator does not stop he may be 
shocked to find a hole curetted through the uterus and the 
abdominal cavity entered. That is not an unheard of 
happening and must be kept in mind in every curettage that 
is done. The uterus must be relatively empty but it is an 
impossibility to get it absolutely clean. The remaining bits 
of decidua will come away in the lochial discharges and the 
patient will make a normal convalescence. 

Not infrequently the uterus will not contract well even 
when you are reasonably certain that it is empty. A small 
sterile gauze wick packed into the uterus and a subcu- 
taneous injection of ergot will without fail make the uterus 
act well. If you do not wish to pack the uterus, a hot in- 
tra-uterine douche (iio°) of sterile water will many times 
prove satisfactory. I never use, however, in these cases, a 
douche, much preferring a small pack which is removed in 
twelve hours. The after care of these cases is simple. The 
bowels should move each day. The diet after the nausea 
from the ether is over is the diet the house presents. No 
medication is indicated unless some unforeseen complica- 
tion arises. Sterile pads are used to collect the lochia and 
are changed as often as necessary. The amount of lochia is 
usually slight, depending upon how far advanced the patient 
is in the pregnancy. 

The length of time in bed varies also for the same reason. 
A week is usually sufficient for a miscarriage up to four 
months. However, it is safe to say that a very small per- 
centage of the women who do miscarry up to this period of 
gestation stay in bed a week. Many women date their 
period of ill health as beginning from a badly managed mis- 
carriage. After they are out of bed they should slowly 
resume their normal life. Menstruation is established at 
varying periods. Each woman is a law unto herself and no 
honest predictions can be made as to when the periods will 



MISCARRIAGE. 5 1 

again begin. The question of pregnancy should not be en- 
tertained at least for six months. 

The causes of miscarriage are varied. For a most com- 
plete classification of the causes the reader is referred to 
that excellent book of Taussig's on the "Prevention and 
Treatment of Abortion." 

Case 8 is typical of one type of miscarriage that phy- 
sicians as a whole do not recognize, namely, that caused by 
the automobile. I am confident that the automobile is a 
potent cause. Carefully used during pregnancy (see page 
Sy) it is a source of pleasure and no harm; recklessly used 
it causes many miscarriages. The slow onset generally 
twelve or even twenty-four hours after the damage is done, 
the dark red, often brown or almost black discharge, with 
no accompanying pains are all characteristic of this type of 
miscarriage. The most common causes of miscarriage are 
syphilis and chronic nephritis. The latter can be ruled out 
by a physical examination with special care given to exami- 
nation of the heart and the night and day urines. The 
Wasserman reaction in competent hands will tell of the 
absence or presence of syphilis. 



SECTION III. 
NORMAL PREGNANCY. 

Case 9. Normal Multiparous Pregnancy. Labor 
Occiput Left Anterior. Patient is seen for the first time 
January ist. Her first baby was born twenty-one months 
ago. It was a breech delivery. The baby weighed seven 
pounds, twelve ounces, and since birth has done well. 

The patient's last menstruation began on September 29, 
and lasted four days. Her menstruation comes every 
twenty-eight days, occasionally one to three days early. 
There was no October period. 

She has had practically no nausea, but for the past two 
months upon awakening has had an annoying frontal head- 
ache, which wears off toward noontime. Occasionally she 
has very acid eructations, and for this she takes milk of 
magnesia with immediate relief. Her appetite is excellent. 
Bowels are regular without medicine. She passes her urine 
now five or six times a day and gets up out of bed to void 
twice at night. She is drinking three cups of tea, two cups 
of coffee, and two to three glasses of water a day. Were it 
not for the morning headaches she would feel very well. 
She wears glasses for reading and sewing. She has not had 
her eyes examined for over a year. For the past month her 
sleep has been disturbed by the first child who has been 
sick, and she has had considerable mental worry because of 
domestic difficulties. 

Examination of a specimen passed in the ofifice showed no 
albumin to be present and no reduction by Fehlings' test. 
Her blood pressure was 119 mm. of Hg. 

Vaginal Examination : — Lacerated perineum on the 
right, slight prolapse of the anterior vaginal wall, slight 
bilateral tear of the cervix. Cervix is soft and in normal 
position. Uterus is in anterior position and corresponds in 
size to a normal three months pregnancy. Nothing abnormal 
felt on the sides. Rectum is full of hard fecal matter. 

53 



54 CASE HISTORIES IN OBSTETRICS. 

I went over with her the various points in the hygiene of 
her pregnancy, stopped all tea, allowed her to have one cup 
of coffee, told her to drink enough water, milk or cocoa to 
pass at least three pints of urine, and advised her to have 
her eyes examined at once because of her headaches. Al- 
though she says her bowels move well it is evident that they 
do not. She has at times taken citrate of magnesia for con- 
stipation, and she was told to take her usual dose every 
morning for the next two weeks. She is to take a half hour 
rest morning and afternoon. 

January 8. The oculist can find no indication to change 
her glasses and says the condition of the eyes will not give 
her the headaches. Specimen of urine, 24-hour amount four 
pints, color normal, acid in reaction; specific gravity 1.010, 
albumin absent by nitric acid, sugar absent. Sediment 
slight. Occasional leucocyte; few round cells; no casts. 
Much vaginal epithelium. 

January 16. Note to-day says that she is resting each 
day; that her bowels are more freely open and that her 
headaches have nearly gone. 

February 9. Reports at the office. Is taking her rests 
regularly. Bowels are moving regularly with the citrate of 
magnesia. Now has no headaches. Blood pressure 122. 
Analysis of urine normal. 

March 14. Telephones this morning that she has a severe 
headache and has vomited twice. I went to her at once. 
Blood pressure 120; pulse 80. No edema of the face, 
wrists or ankles. Bowels have moved twice to-day. Urine 
which she was collecting for the twenty-four hour amount 
was high in color. Albumin by nitric acid absent. 

For the past ten days she has had but little sleep because 
of sickness in the family. She knows of nothing she has 
eaten which could have caused this condition. It was evi- 
dent that this upset was nothing more than over-fatigue 
causing a slight indigestion, and that a good night's rest 
would without doubt make her feel well again. Family mat- 
ters were so arranged that she obtained a much-needed 
sleep and in forty-eight hours she was as well as before. 

July 2. She has been seen once a month and her urine 



I 



NORMAL PREGNANCY. 55 

examined regularly on the first and fifteenth of each month 
from the sixth month. All urinary analyses have been nor- 
mal. She has been in excellent condition. Palpation to-day 
shows a good-sized baby lying in a left position. Head is 
settling into the brim. Fetal heart is heard in the left 
lower quadrant, 130 to the minute. While palpating the 
uterus there were three definite contractions, unaccompanied 
by pain. 

July 5. Telephone from the nurse that in the last half 
hour the patient had had three contractions with slight 
pain, and after the last one there was a slight show of blood- 
tinged mucus. I started for the patient at once and when 
I arrived, two hours later, she was having slight pains every 
ten minutes. The nurse had withheld the enema up to 
this time. Preparations were speedily completed. The 
enema was given and a good result obtained. Almost at 
once the pains became stronger, but the interval remained 
the same. Palpation showed a probable O. L. A. position; 
biparietal diameter is through the brim and the head is 
well flexed. Fetal heart is 120 in the left lower quadrant. 
The uterus is soft and not tender between pains. There is 
no history of the rupture of the membranes and no liquor 
comes away with pains. Her temperature is 98.6° and 
pulse 72. From now, 11 p.m., until six a.m. July 6th she 
had pains every eight minutes, lasting at first a half to three 
quarters of a minute. At about five they lasted a full 
minute, and about every other one lasted a minute and a 
half. The uterus relaxed well and the fetal heart remained 
at 120. At six- thirty the pains changed in character, began 
coming every three minutes and she began to have an in- 
clination to bear down. The pains now were very hard and 
she asked for ether and it was given her with each pain. 
Palpation showed that the head had descended so that it 
could just be reached from above. There was no bulging 
and there was a moderate amount of "show." At seven 
a.m. vaginal examination showed the head on the perineum 
and a tense bag of forewaters. Posterior lip of the cervix can- 
not be reached; anterior is just felt and is very thin. As a 
pain ceased the sagittal suture was readily felt in the antero- 



56 CASE HISTORIES IN OBSTETRICS. 

posterior diameter of the pelvis. The membranes were now 
ruptured by a rat-tooth forceps and much clear liquor came 
away. She was at once put in the left lateral position. 
With each pain she worked well, and with each pain she 
had obstetrical ether. She was conscious between pains and 
not uncomfortable. At the end of a very few pains the 
perineum began to bulge and steady progress was made. 
When the scalp appeared it was seen that the circulation 
was excellent. The head was held back for several pains, 
and the ether was forced so that she was unable to bear 
down at all. The uterus alone was contracting. The 
perineum softened up well, and between pains the head was 
shelled out. The occiput restituted to the left. Eyes 
wiped off with sterile gauze and mouth cleaned out; cord 
felt for and found about the neck. Traction made in order 
to slip it over the head, but it was too tight and it was also 
too tight to slip over the shoulder. Immediately put on the 
cord two half-length clamps and cut between them. The 
anterior shoulder was then drawn down under the arch and 
was readily delivered and the posterior followed. The 
nurse followed down the uterus, and the body was delivered 
without difficulty. The baby cried at once, was thoroughly 
drained and put aside. Ether was stopped as soon as the 
baby was born. 

The uterus relaxed more than usual and the nurse had 
some difficulty in making it contract. The patient quickly 
came out of ether and was rolled over on her back and her 
legs steadied by the nurse. Examination of the perineum 
showed no fresh tear. 

The baby was born at 7:43 a.m. and at 8 a.m. the placenta 
came away intact with all the membranes. The patient's 
pulse was 72, and at no time had it been over 90. She was 
cleaned up, sterile dressing put on the vulva and she was 
put back to bed. The uterus acted poorly, relaxing con- 
stantly and filling up with blood so that many large clots 
were expelled from it. Ergot was given intramuscularly, and 
with careful holding of the uterus it soon began to act better. 
The cord was tied with two ties of bobbin. There was no 
bleeding. The baby was wrapped up in a blanket with a 



NORMAL PREGNANCY. 57 

hot- water bottle nearby and put carefully aside until the 
nurse was ready to wash it. Examination of the baby 
showed it to be a normal child. It weighed eight pounds. 
After it was washed on listening to its respiration the lungs 
were found to be expanded. The heart sounds were normal. 

About nine o'clock the patient was given a cup of cocoa 
and it did not distress her. By ten the uterus was acting 
well and staying firmly contracted and the nurse then put 
on the abdominal binder. The patient voided urine with- 
out difficulty. 

The following orders were left with the nurse: 

1. Four-hourly temperature and pulse chart until the 
milk is well established. 

2. Report excessive flowing or rise in pulse. 

3. Soft solid diet until the bowels move. 

4. Crede the uterus every four hours; oftener if it fills up 
with blood clot. 

5. Watch baby for mucus. 

6. Watch cord for bleeding and report at once if any. 

7. Give baby two drams of boiled water every four hours. 

8. Nurse baby for two minutes on each breast late this 
afternoon and to-morrow every four hours for five minutes 
on alternate breasts. 

I left at 12 M. both patients in excellent condition. 

July 7. Temperature 98.6°; pulse 58. Fundus hard, at 
the level of the umbilicus. Abdomen slightly distended; 
bowels have not moved. Has voided several times. Lochia 
profuse and red; normal odor. Breasts not filling up but 
colostrum can be expressed. Baby took hold of the nipples 
well yesterday and started up severe after-pains, which lasted 
for one hour. 

Baby has voided and passed several large movements of 
meconium. The patient was given this noon half an ounce 
of castor oil. To-morrow she is to have her regular diet. 

July 13. Temperature has been normal; pulse varies 
from 70-80. Lochia is still considerable and red in color; 
normal odor. Fundus is firm and is felt at the symphysis. 
Breasts are soft but full. No cracks in the nipples. Baby 
is nursing now every two hours for ten minutes on alter- 



58 CASE HISTORIES IN OBSTETRICS. 

nate breasts and is satisfied. Mother's bowels move daily 
with a five-grain tablet of cascara in the evening and an 
enema in the morning. 

The baby is gaining now an ounce a day; movements, 
seven or eight a day, bright yellow and smooth. The um- 
bilicus is moist and has a slight odor. The cord, except for 
the vein, is entirely separated. Umbilicus and vein wiped 
with 70% alcohol, dried with a sterile sponge and the vein 
religated with sterile bobbin. Umbilicus powdered with 
bismuth subgallate and sterile gauze put over it with the 
band to hold it in place. 

July 17. Telephone from the nurse at 11 p.m. that the 
patient was complaining of pain in the left breast. It was 
tender to the touch; it was not full and no lump could be 
felt. The baby had nursed from it at 10 p.m. The patient 
had not spoken of any discomfort in the breast until after 
the nursing was over, but she then said she had had some 
pains since the afternoon but that it had only just become 
tender to the touch. Temperature 98.6°; pulse 72. I told 
the nurse to put an ice-bag at once to the breast; to keep a 
four-hourly chart, to let the baby sleep after its 2 o'clock 
nursing as long as it would and not to nurse from this left 
breast until after telephoning me. 

July 18. At midnight temperature 101.2°; pulse 92. 
Breast was tender and full, and the patient complained 
of a severe headache. At 3 a.m. temperature 102°; pulse 
92. At seven this morning when the nurse telephoned the 
temperature was 98.8°; pulse 68. The baby was still asleep. 
She was told to nurse the baby when it waked, on the right 
breast and to give the baby an ounce of a modified milk, fat 
3.00%, sugar 6.00%, proteid 1.00%, no heat, no lime water, 
for its next feeding. At 12 noon the temperature was 
98.8° and the pulse 70. I told the nurse to let the baby 
nurse from the left breast, but as soon as the nursing was 
over to reapply the ice-bag. I saw the patient at four this 
afternoon. The temperature was 98.8°, pulse ']2. In the 
lower inner quadrant is a lump the size of a pigeon's ^%% 
which is not tender. The baby nursed at four from the 
left breast and it caused no pain. Ice was kept on the 



NORMAL PREGNANCY. 59 

breast until lo p.m. The temperature at that time was 
normal and the pulse 70. 

July 19. Morning temperature 99"^, pulse 80. I saw her 
at noontime. Temperature 99°, pulse 72. Breast is full, 
but no definite point of tenderness made out. No lump 
felt. Told the nurse to take the ice-bag off one-half hour 
before nursing is due on this breast and then to let the baby 
nurse. Ice-bag then to be reapplied. If no temperature 
at four to nurse again. The baby's umbilicus is solidly 
healed. 

July 20. Terhperature has remained normal. Pulse 
60-70. Small lump is felt by the nurse in the left breast, 
but it is not tender. 

August 4. The baby is not satisfied on the breast, cries 
after its nursing, and wakes up before it is time to nurse. 
Put on to supplementary feedings of a fat 3.00%, sugar 
6.00%, proteid 1.00%, no heat and no lime water, of 
one-half to one ounce, depending upon how much breast 
milk the baby obtained, as shown by weighing before and 
after nursing. 

Vaginal Examination : — Fair perineum showing the 
previous tear. Very slight bilateral tear of the cervix. 
Uterus normal in position and size. Nothing abnormal felt 
on the sides. No tenderness present in the pelvis; no 
vaginal discharge. Breasts are soft; no lump can be found. 
No cracks in the nipple. Baby's umbilicus is healed, and 
there is no bulging. Movements are well digested, yellow in 
color, four to six in number, each twenty-four hours. 



60 ^ CASE HISTORIES IN OBSTETRICS. 

Case 10. Occiput Right Posterior. Normal De- 
livery. The patient is seen for the first time January lo. 
She now is six months advanced in her third pregnancy. 
Up to the present time she has been under the care of her 
physician out of town, but she now has come in town to stay 
until the delivery is over. 

Her first pregnancy was a long thirty-six hour labor but 
she finally delivered herself with severe lacerations. She 
was repaired at once but she says the stitches did not hold. 
Her second pregnancy followed two years later and she 
again delivered herself and again was badly torn. This 
time she says she thinks the stitches held. The children 
weighed eight and eight and a half pounds. She was not 
allowed to have ether at either delivery. 

The present pregnancy follows the last at a three-year 
interval and dates from her last menstruation which was 
June 30. It had the usual characteristics. There was no 
period in July. She expects to be confined about April 6th. 
She is in excellent condition, bowels are moving regularly 
with the help of one five-grain tablet of cascara. Is drink- 
ing six to eight glasses of water each day. Her appetite is 
excellent and she sleeps well. She says that the examina- 
tions of her urine have all been reported as normal. She 
was told to collect the twenty-four hour amount and to 
send a four-ounce specimen from this mixed quantity. 

January 12. Specimen normal in color, acid, specific 
gravity i.oio. Albumin by nitric acid absent; sugar, no 
reduction by Fehling's solution. Amount three pints. The 
patient reports at the office the first of February and March 
bringing with her a specimen of urine. She is in excellent 
condition and the analyses of the urine were normal. 

March 18. Palpation of the abdomen to-day shows a 
large baby. Fetal small parts readily felt on the patient*s 
left. Firm smooth resistance on the right. The head is felt 
at the brim and is freely movable. The baby is very lively 
and causes the mother much discomfort. Fetal heart is 
best heard in the right lower quadrant, 120 to the minute. 

April 8. At five o'clock this morning patient was awakened 
by several slight pains but they soon passed off and she had 



NORMAL PREGNANCY. 6 1 

no more. At 2 : 30 p.m. after a quiet morning with no con- 
tractions patient telephones that she is having sHght pains 
every half hour and that they began at noon. The nurse was 
sent for and an hour later when she arrived the pains were 
coming regularly every fifteen minutes lasting thirty seconds 
but were very sharp. She was prepared at once. Her tem- 
perature was 98.6° and her pulse 80. I arrived at the patient's 
house at 3 : 45 p.m. Pains were then coming every eight min- 
utes, from forty-five seconds to a minute in duration. 
There was no show. The uterus was relaxing well between 
pains. Palpation showed the head well in the pelvis. Mem- 
branes had ruptured a few moments before I got to the 
house. The fetal heart was 120 to the minute and regular. 
Vaginal examination was made with patient on her left side. 
Examination showed the os practically fully dilated. Noth- 
ing but the thin anterior lip could be felt. Head within an 
inch of the vulva. Posterior fontanelle on the right, in the 
transverse diameter of the pelvis. Anterior fontanelle can- 
not be felt. Pains now came every three minutes markedly 
increasing in severity and lasting one to one and a half min- 
utes. Uterus was relaxing well between each pain. Not 
tender. Obstetric ether was now given to her. At 4:45 
all the preparations for delivery were complete. The ether 
worked beautifully and she remained in excellent position. 
With each pain she now worked hard. At five p.m. the 
perineum began to bulge and with each succeeding pain 
advance was made. At 5:15 the scalp appeared at the 
vulva. The circulation as shown by pressing the finger on 
it was excellent. Ether was now forced with each pain 
and also during the interval. She soon was fully under 
its influence and the uterus alone was working. For some 
minutes the head was held back until the perineum was 
fully stretched. The scar from the first delivery could 
readily be seen running to the sphincter. The head was 
finally allowed to come along between the pains. The 
occiput restituted to the right showing the position to have 
been an O. D. P. The cord was at once felt for but was 
not found. The eyes were wiped clean with a sterile sponge 
and the mucus wiped from the mouth. On the next pain 



62 CASE HISTORIES IN OBSTETRICS. 

the anterior shoulder came down under the arch and with- 
out difficulty the shoulders were delivered and then the 
body. Care was taken to keep the shoulders and body off 
the perineum as much as possible. Ether was stopped as 
soon as the child was born. The patient was absolutely un- 
conscious at the delivery. The baby cried at once vigor- 
ously. As soon as the cord stopped beating it was clamped 
and cut. The uterus was followed down during the de- 
livery by the nurse and after the delivery was held by her. 
The uterus continued to contract and one-half hour later 
the placenta was expelled intact with all the membranes. 
The patient was still lying on her left side somewhat ether- 
ized. There was no bleeding and the uterus acted well. 
She was now rolled over on her back in lithotomy position 
and the perineum examined. There was no external tear. 
There was a slight internal tear on the left which was re- 
paired at once with two chromic catgut sutures. She was 
then cleaned up, a sterile pad put on the vulva and made 
comfortable in bed. Pulse immediately after the delivery of 
the placenta was 65. The uterus was firmly held for forty- 
five minutes because of the very severe after-pains she had 
after her second delivery when the uterus was not held at 
all. Baby weighed 8 pounds and 14 ounces. At 7:30 p.m. 
she was in excellent condition. Temperature 100°, pulse 70. 
She was having slight after-pains for which I ordered a 
half grain of codeia by mouth if they kept her awake. 

April 9. With the help of the codeia she had a fair night. 
She voided urine without difficulty. Pulse 72. Temper- 
ature 98.6°. 

April 10. Slept eight hours. The breasts are flabby and 
no milk can be expressed. The baby is hungry and was put 
on a modified milk of fat 2%, sugar 6% and proteid 1%. 
No heat and no lime water. Half an ounce every four 
hours. Patient's bowels moved this morning by enema 
and a good result obtained. 

April II. Milk came in with a rush this morning and the 
baby is to be put to the breast every two hours. The nursing 
started up severe after-pains and this afternoon she passed a 
clot the size of a baby's fist. Temperature 98.6°, pulse 70. 



NORMAL PREGNANCY. 63 

The convalescence was absolutely normal and she got up 
on the twenty-first day. There was no flow. Examina- 
tion on the twenty-fourth day under aseptic precautions 
showed slight bilateral tear of the cervix. Uterus in first 
degree retroversion. Normal in size. No tenderness. 
Freely movable. No tenderness in the pelvis. Perineum 
shows tear in both sides, from the two previous deliveries. 
Sutures which I placed are present and apparently held the 
tear in good approximation. Patient went to her home on 
the twenty- fourth day in first-class condition as was the 
baby. 



64 CASE HISTORIES IN OBSTETRICS. 

Case II. Normal Pregnancy and Labor. Occiput 
Left Anterior. Patient is seen for the first time May 5. 
She has been under the care, up to the present time, of her 
family physician but from now on she is to be under my 
care for deHvery. Her last menstruation was August 23rd, 
making delivery due the first week in June. She has had 
an absolutely normal pregnancy and the urinary analyses 
her physician tells me have all been normal. At no time 
has the blood pressure been over 120 mm. of Hg. Her 
first baby, which weighed eight and a half pounds, was born 
eighteen months ago. Normal delivery. She was told that 
she was slightly torn. The tear was repaired at once by 
two stitches. Three months after the first child was born 
she complained of much backache and a bearing down 
sensation. She was then examined and the uterus found to 
be in retroversion. It was replaced in position and a pessary 
inserted. By wearing the pessary she is absolutely com- 
fortable. Pessary in the present pregnancy was taken out 
at the beginning of the fourth month. Palpation to-day 
shows a fair-sized baby. The back is on the left. Small 
parts definitely made out on the right. The head is but 
slightly movable in the brim at the present time. Fetal 
heart is 130 to the minute in the left lower quadrant. Vag- 
inal examination not made. 

May 24. Telephone from the nurse at half-past seven 
that her patient had started in labor and that for the last 
hour has had pains every twenty minutes with good uterine 
contractions. I saw her at nine. She has not had any 
pains for the last half-hour, and in the next half-hour had 
none. Palpation the same as before except that the head 
by means of the fourth grip is well in the pelvis. Fetal 
heart 130 in the left lower quadrant. The patient is not in 
labor and I left orders that I be notified at once when the 
pains begin. 

May 29. Telephone from the nurse at half past five a.m. 
that the pains had started at half-past four every twenty 
minutes and that now the last two pains had come at five- 
minute intervals, that the membranes had not ruptured. I 
went to her at once. At half -past six the pains were coming 



NORMAL PREGNANCY. 65 

every eight minutes lasting half to three-quarters of a min- 
ute. Palpation shows a definite O. L. A. position. Fetal 
heart 130 in the left lower quadrant. Head can just be 
reached from above by the fourth grip. Uterus is soft be- 
tween pains but during a pain contracts well. Patient's 
pulse is 80. Temperature 98.6. 

9:30 A.M. Pains have gradually increased in strength and 
are now lasting a minute to a minute and a half with in- 
tervals of two minutes. Vaginal examination showed the 
OS fully dilatable. Posterior lip can just be reached while 
the anterior lip is thick and readily reached. The head is 
on the perineum and the saggital suture is in the antero- 
posterior diameter. At quarter-past ten the patient began, 
of her own accord, to bear down and there was the slightest 
suggestion of bulging. Membranes had not ruptured. At 
half-past ten I ruptured the membranes and for twenty 
minutes all pains stopped. At five minutes of eleven she 
had a hard long pain and the perineum bulged. Prepa- 
rations for the delivery had been completed and she was at 
once put in the left lateral position for delivery. Pains now 
began coming every three minutes, lasting one minute. She 
refused absolutely all ether and said she "wanted the sen- 
sation of doing it all herself." She worked well with each 
pain, holding her breath and pulling on the sheet which was 
tied to the footboard of the bed. She very quickly brought 
the occiput in sight and at ten minutes past eleven the head 
had to be held back in order to let the perineum gradually 
stretch up. Patient acted splendidly. As soon as the per- 
ineum was on the stretch the sheet was taken away from 
her and she used only her abdominal muscles to bear down. 
On the next pain she was made to pant; the uterine muscle 
alone was acting. The head was delivered readily between 
pains and the occiput restituted to the left. Cord not 
around the neck. Eyes wiped off with sterile gauze. Mouth 
cleaned out. With no difficulty the shoulders followed on 
the next pain. The baby cried at once and the cord was 
pulsating. The nurse followed down the uterus well. The 
baby was held up by the feet and thoroughly drained. 
There was no bleeding. When the cord stopped pulsating it 



66 CASE HISTORIES IN OBSTETRICS. 

was tied and cut and the baby carefully done up and put 
away. Patient was turned on her back and her legs were 
steadied by the nurse. Twenty-five minutes after the baby 
was born the placenta came away spontaneously, intact 
with all the membranes. Examination of the perineum 
showed no fresh tear. The patient was in excellent con- 
dition. The uterus acted well and stayed hard. Pulse 90. 
She was cleaned up and a sterile pad put over the vulva. 
The uterus was held for about twenty minutes and it did 
not relax. Pulse dropped to 80 and the nurse then put on 
the swathe and the patient was made comfortable in bed. 
Left the patient at half past twelve with a pulse of 80 and 
uterus hard. No oozing and in excellent condition. 

Evening visit. Patient has voided. Uterus is hard and 
lochia is normal in amount and character. There is a slight 
amount of colostrum in the breast and the baby is to be 
put to the breast every four hours. Temperature 100.5°, 
pulse 72. 

May 30. Temperature 98.6°, pulse 72. Uterus is hard 
and not tender, at the umbilicus. Lochia is normal in 
amount and in character. Breasts are soft and not filling up. 
Baby took hold of the nipple well; it has voided and passed 
meconium. It weighed at birth seven pounds and fourteen 
ounces. Castor oil, one ounce, ordered to be given early 
to-morrow morning, to the mother. 

June 2. Temperature to-night 98.4°, pulse 70. Uterus is 
hard and felt just above the pubes. Lochia is scant. There 
has been nothing on the pad since noontime to-day. Breasts 
are full and slightly tender, but the baby is nursing now 
every two hours and nurses them out fairly well. Bowels 
have been moved daily by an enema. 

June 8. Temperature has been normal. Pulse varying 
from 60-80. Uterus can just be palpated from above. 
Occasionally there is a slight amount of lochia on the pad. 

June 12. Both mother and child have done well. The 
baby is nursing regularly every two hours for fifteen min- 
utes, and is gaining one to two ounces a day. Patient 
began her leg exercises to-day. (Page 129.) Uterus cannot 
be felt from above and the lochia has practically ceased. 



NORMAL PREGNANCY. 67 

She IS to sit up for one meal a day for the next three days, 
and if the lochia does not increase is then to sit up in bed 
for all of her meals each day. 

June 16. Lochia has not increased. Leg exercises have 
made her abdominal muscles slightly lame. Baby is doing 
well but the umbilicus is not quite dry. 

June 18. Examination to-day shows the uterus is normal 
in size and normal in position. Bilateral tear of the cervix. 
There is a marked cystocele and a slight rectocele present 
on bearing down. Because of her previous history pessary 
was put in before she got out of bed. 

July 5. She is about her house feeling absolutely well. 
No vaginal discharge. No sensation in the pelvis of bearing 
down. She is going away for the summer and her local 
doctor is to change the pessary once a month. The breasts 
fill up well in between nursings and are soft. Baby's um- 
bilicus is healed. Movements are normal and both patients 
are in excellent condition. 



68 CASE HISTORIES IN OBSTETRICS. 

Case 12. Normal Multiparous Labor O. D. P. Re- 
tained Membranes. The patient is seen for the first 
time June 1st. She is seven months advanced in her fourth 
pregnancy. Her first two pregnancies ended in normal de- 
liveries. In the third the membranes ruptured before the 
onset of labor, and after a long, tedious, inefficient labor 
she was delivered by high forceps. She made an excellent 
convalescence from all these deliveries. Her last period be- 
gan on November 19th. In her three other deliveries she 
has reckoned the date correctly to the day each time. 

Urine analyses have all been reported as normal up to the 
present time. From now on to the end of her pregnancy 
the urine was examined once in two weeks. The amount of 
urine has always been between three and four pints, there 
has been no albumin present, and there has been no reduc- 
tion by Fehling's solution. 

July 28, She is in excellent condition. Is walking about 
a mile each day and goes in swimming nearly every day. 
Palpation of the abdomen shows a fair-sized baby. The 
back is on the right. Small parts definitely made out on 
the left. The anterior shoulder is readily palpated well 
forward to the left of the median line. The head is at the 
brim, freely movable. Fetal heart is best heard in the right 
lower quadrant, 120 to the minute. 

August 4. She is sleeping poorly. Motion of the baby is 
very active and causes her much discomfort, but no real 
pain. For the past three days she has been having con- 
tractions of the uterus accompanied with slight pain. They 
come irregularly in frequency and in strength. While I was 
talking with her, she had in ten minutes three contractions 
with definite pain in the lower abdomen. For the past week 
she has been drinking but three glasses of water a day, and 
she has been constipated. She was told to drink at least 
ten glasses of liquids, and to increase the dose of cascara, 
enough to get one good movement each day. For her sleep- 
lessness she was given trional gr. x at bedtime. 

August 10. She has taken the trional three or four times 
since last note and has had good nights. Her bowels now 
are regular and she is passing sufficient urine, analysis of 



NORMAL PREGNANCY. 69 

which is normal. The past three days the contractions have 
not been marked and the baby has moved practically not 
at all. 

August 25. The patient telephones this morning that for 
the past two nights she has been having pains for an hour 
or two with good contractions, coming at irregular intervals 
of five to thirty minutes. They then would cease and she 
would sleep for the remainder of the night. There has been 
no show. At one o'clock this afternoon the pains began 
coming regularly every fifteen minutes and she says she feels 
them more in her back than at any other place. The nurse 
at once prepared her for delivery. From three to four p.m. 
the pains came every eight minutes. They then stopped 
entirely. 

At seven p.m. the pains started up again and began, at 
once, coming every five minutes, lasting one minute. The 
uterus relaxed well between the pains. Palpation showed a 
right position as before. Head is freely movable at the 
brim. Fetal heart is 128 and regular. There is a very 
slight show. From now until eleven the pains continued 
severe every five minutes, lasting one minute. 

II p.m. Vaginal Examination: — Posterior lip of the 
cervix is thin and can just be reached; the anterior is much 
thicker. The membranes are bulging through the os and are 
very tense. The head can just be reached and is freely 
movable above the brim. She has no inclination to bear 
down. Preparations for delivery are completed at once. 

From eleven to twelve the pains were less severe and came 
at seven-minute intervals and lasted one-half to three- 
quarters of a minute. At 12:30 a.m. the pains were very 
severe, coming every two minutes, lasting three-quarters of 
a minute. Obstetric ether was now begun. She now had 
the slightest inclination to bear down. Everything was 
ready for the delivery. 

Patient was put across the bed in lithotomy position. 
With a sterile towel over the lower abdomen the head was 
grasped by the left hand and pushed into the brim and as a 
pain was going away the membranes were ruptured. Clear 
amniotic fluid came away. The head at once descended. 



70 CASE HISTORIES IN OBSTETRICS. 

No cord was felt. The nurse listened to the fetal heart and 
it was regular. The patient was at once turned to the left 
lateral position. 

No pains came for ten minutes. They then returned 
every two minutes. With each pain she worked well and 
after a few pains the perineum began to bulge. Ether was 
now forced with each pain. The scalp appeared at once. 
She made very rapid progress. The head was carefully de- 
livered between pains. No cord about the neck. Eyes 
wiped off and mouth cleaned out. Shoulders born without 
difficulty as was the body. The baby cried at once. The 
baby was born at i a.m., August 26. Uterus contracted 
well. Ether was stopped when the baby was delivered. 
Pulse 90. The cord after it stopped beating was clamped 
and cut. The patient soon came out of ether and was 
turned on her back across the bed. Twenty- five minutes 
later the placenta was delivered intact, but the membranes 
did not all come with it. A hemostat was snapped on the 
piece of membrane protruding from the vulva and with 
careful twisting more of the membranes were removed. 
By inspection it was very evident that all were not re- 
moved. There was no bleeding. The uterus contracted 
well. Examination of the perineum showed no fresh tear. 
Pulse 90. 

Patient was cleaned up and a sterile pad placed over the 
vulva. She was put back to bed in excellent condition. 
Uterus stayed well contracted, normal amount of flow. 
Pulse dropped to 80. \ 

One hour after delivery was completed the pulse was yS, 
uterus hard, normal amount of flowing. I then told the 
nurse to put on her binder. The baby weighed 8 pounds, 
4 ounces and was in excellent condition. 

August 27. Temperature normal, pulse 72. Uterus hard, 
on the level with the umbilicus. Not tender. Breasts 
flabby, but a slight amount of colostrum can be expressed. 
Baby ordered to breast once in four hours for three minutes 
on each breast. Patient has voided. Lochia is profuse and 
bright red, and this morning the nurse expelled from the 
uterus one small clot. The patient is slightly distended and 



NORMAL PREGNANCY. 7 1 

a suds enema ordered. Castor oil, half an ounce, ordered 
to be given sometime early to-morrow morning. 

August 29. Temperature has not been over 99°. Pulse 
has ranged between 70 and 80. Lochia is much less pro- 
fuse; light in color. Yesterday a long strip of membrane 
was found on a pad. The lochia is of normal odor. Uterus 
is firm and two finger's breadth above the symphysis. The 
milk came in slowly. The baby now is nursing regularly 
every two hours and is satisfied. Patient's bowels are mov- 
ing regularly with five-grain tablet of cascara in the evening 
followed by a small enema in the morning. 

September 10. Has made an excellent convalescence. 
Uterus cannot now be felt above the symphysis. She has a 
slight vaginal discharge which now and then is streaked 
with blood. She has been sitting up in bed for her meals 
since the fourteenth day. She began her exercises on the 
fourteenth day and they have not increased the lochia. 

September 25. Patient got out of bed on the twentieth 
day and walked to the bathroom. She had no ''pins and 
needles" in her feet. She has gradually increased her walk- 
ing and on the twenty-fourth day went downstairs once. 

A slight bloody vaginal discharge appeared to-day which 
the patient thinks is the return of her menstruation. She 
says that after her second pregnancy she began menstruat- 
ing one month after her delivery and continued regularly. 
She therefore was not examined at this time. From now on 
she is slowly to resume her usual duties and is to report to 
me if the menstruation does not cease in the usual time. 
The baby is doing consistently well. 

October 13. I did not see this patient again until to-day 
and she has made no report to me since the last note. She 
says she has been bothered now and then with a slight bloody 
discharge. At no time has it been marked except once 
when she was standing up having dresses fitted. She then 
soaked through two pads with bright red blood in one hour. 
At no time since the last note has she felt she could go with- 
out a pad because of this discharge. She refused a vaginal 
examination at this time. She was given a prescription for 
equal parts of the fluid extracts of ergot and hydrastis and 



72 CASE HISTORIES IN OBSTETRICS. 

told to take a teaspoonful every four hours for three days. 
If at the end of this time she had not stopped flowing entirely 
she was told she must be examined to determine exactly the 
cause of the flowing. To this she agreed. 

October i6. Patient telephones to-day that there has 
been no discharge for twenty-four hours, that she was not 
wearing a pad and was feeling well in every respect. 

October 24. This evening she telephones that she has 
been flowing occasionally for the past forty-eight hours and 
has had to use in the last twenty-four hours six napkins. No 
clots have been passed. Except for this flowing she has been 
perfectly well and is nursing the baby which is doing well. 

October 25. She comes to the office to-day for examina- 
tion. 

Vaginal Examination: — Slight old lacerations of the 
perineum. No bulging on straining, slight bilateral tear of 
the cervix with slight erosion, which does not bleed when 
touched. There is a bloody, thick, stringy discharge coming 
from the cervix. The uterus is in third degree retroversion. 
It is not tender, but is soft and enlarged. There is nothing 
felt on the sides and there is no tenderness in the pelvis. 
By bimanual manipulation the uterus was replaced with 
ease and it did not when left alone fall back into retroversion. 
It was again found to be enlarged and very soft. A pessary 
was inserted in the vagina which held the uterus in ex- 
cellent position. 

October 29. Twenty-four hours after the pessary was 
put in all flowing stopped and there has been none since. 
Vaginal examination shows the uterus held in normal posi- 
tion and of normal size. It is distinctly smaller than at the 
last examination and less soft. The pessary causes no dis- 
comfort. Inspection shows that there are no abrasions 
present in the vagina. Pessary cleaned and replaced. 

December 4. Patient reports at the ofhce to-day. There 
has been no flowing since the last visit. She feels perfectly 
well. Is nursing her baby and it now has one bottle a day 
and she is taking entire charge of it. She says she has no 
discomfort from the pessary and would not know it was 
present. 



NORMAL PREGNANCY. 73 

Vaginal Examination: — Uterus in normal position, 
small and firm. Pessary removed. Inspection shows no 
abrasions present. Pessary cleaned and replaced. 

Further history of this case was that she came into the 
office to have the pessary cleaned and replaced every six 
weeks. Menstruation returned five months after the birth 
of the baby and was in all respects normal. The pessary 
was worn for six months after it was first inserted and then 
removed. Two months after it was removed she was ex- 
amined by vagina and the uterus was found in normal 
position, very small and firm, freely movable and not tender. 
She was still nursing her baby with the aid of two bottles 
and the baby has done consistently well. 



The uterus was noticeably small. This is not an unusual 
occurrence in a nursing woman; the name given this con- 
dition is lactation atrophy. It is a well -recognized con- 
dition and when found should cause no surprise. Gradually 
after nursing is stopped the uterus recovers its normal size. 
This condition is usually not so well marked in patients where 
menstruation has returned during the nursing period, but 
that it does appear under these circumstances is proved by 
this case. 



74 CASE HISTORIES IN OBSTETRICS. 

Case 13. Normal Pregnancy and Labor. Slight 
Hemorrhage. Shock. Patient is seen for the first time in 
the present pregnancy May 20th. Her last menstruation 
began March 28th making delivery due about January 7th. 
Her first child was born three years ago next August, after a 
rather difficult high forceps delivery; her second, thirteen 
months later after a quick labor of three hours. From both 
these pregnancies she made a good convalescence. She is 
having but a slight amount of nausea and no vomiting. 
She is very uncomfortable at times because of the acid taste 
in her mouth. Aside from this she is in excellent condition. 
She was reminded of the care she must take of herself during 
this pregnancy and warned not to attempt to do a great 
deal because of the fact of having had the children so rapidly. 
For the acid eructations she was told to take a teaspoonful 
of milk of magnesia as often as necessary for relief and also 
told to rinse out her mouth with this several times a day. 

October 5. Since the last note she has been away for the 
summer. The milk of magnesia relieved her much. Except 
for increasing difficulty in moving her bowels she has been in 
excellent condition. Compound licorice powder and fluid 
extract of cascara were of no avail but phenolphthalein two- 
grain tablets three times a day worked well with her. The 
urine analyses have all been normal. Her blood pressure 
to-day was 120 mm. of Hg. 

December 2. Palpation to-day shows a fair-sized baby. 
The back is on the left. Small parts on the right. Head 
freely movable at the brim. Fetal heart in the left lower 
quadrant, 120 to the minute. Blood pressure 118 mm. of 
Hg. She is passing four pints of urine, analysis of which is 
normal. Bowels moving well every day. 

January 7. 3:30 a.m. telephone from the nurse saying 
that for the last hour the patient had been having contrac- 
tions with slight pains. They were lasting only twenty 
seconds and she said she was doubtful whether the patient 
really was in labor. I told the nurse to telephone again in 
an hour, sooner if necessary. In half an hour she telephoned 
saying the pains were continuing and were now slightly 
harder lasting half a minute and the last two had come at 



NORMAL PREGNANCY. 75 

five-minute intervals and were hard and sharp. I went to 
the patient at once, arriving shortly after five o'clock. From 
the time of the last telephone message to now she had had 
absolutely no pains but had not slept. Fetal heart is best 
heard in the middle line three inches above the pubes, 120 
to the minute. Baby is in a left position. Head is freely 
movable at the brim. From now until half past seven she 
slept in naps and had absolutely no pain. It is very evident 
she is not in labor and I left the patient. 

January 8. Nurse telephones at 12 midnight saying the 
patient has just been awakened by a great amount of motion 
of the baby and the motion was so marked that the nurse 
saw it across the room. It hurt the patient a great deal. 
In the course of few moments motion ceased and then the 
patient noticed that she was having contractions. I reached 
the patient at half past one a.m. Fetal heart was 120 
in the left lower quadrant, loud and regular. Palpation 
showed a definite left position, firm resistance on the left 
with small parts on the right; the head was firmly engaged 
in the brim, biparietal was nearly through the inlet. The 
fingers of the left hand could be pressed down much further 
on the left than could the fingers of the right hand on the 
right side showing the head to be well flexed. No history 
of ruptured membranes. She now was having pains every 
ten minutes lasting from one minute to a minute and a 
half. Pains continued coming every ten minutes and at 
three o'clock palpation showed that the head could just be 
reached from above. At four o'clock pains came distinctly 
harder and she began to bear down with each pain and 
asked for ether. Pains were now of five-minute intervals 
lasting one to one and a half minutes. 

Vaginal Examination with Patient in Left Lateral 
Position: — Examination made just as a pain was begin- 
ning. Introitus relaxed. Head one inch from introitus. 
Good bag of fore waters. Posterior lip of the os not felt, 
anterior edge thin and is readily reached. Sagittal suture 
is in the antero-posterior diameter. As the pain let up I 
ruptured the membranes and clear liquor came away. Fetal 
heart listened to, regular, 120 to the minute. 



"jG CASE HISTORIES IN OBSTETRICS. 

She was now given ether with each pain by the nurse. 
The pains continued to come regularly. Preparations for 
delivery were complete. The patient was in the left lateral 
position and worked well with each pain. In half an hour 
she brought the scalp into view. Circulation was normal. 
As she brought the head further in sight, it was noticed that 
the circulation in the scalp was poor. The chin was caught 
by the left hand behind the anus and delivery hurried by 
means of pressure from behind the anus with this hand. The 
head delivered, the cord felt for and found about the neck. 
Traction on the neck brought the anterior shoulder under the 
arch and the cord slipped back over this shoulder. The pos- 
terior shoulder was then delivered. The body followed with- 
out difficulty. The baby was born at 4:45. The cord was 
not pulsating. The baby was drained at once and mouth 
cleaned out. In a moment it gave a gasp. Heart was 
beating slowly but regularly, about 90 to the minute. The 
baby was very blue. By gentle slapping on the buttocks 
and blowing on the chest it very soon began to breathe reg- 
ularly and became of good color. It then cried lustily. 
Immediately following the birth of the baby a large amount 
of meconium came away. The uterus acted well and it was 
held by the nurse. The cord was tied in two places and 
cut. Ether was stopped at the birth of the baby. 

She was now turned on her back and twenty-five minutes 
after the delivery began to bleed profusely. Vaginal ex- 
amination showed that part of the placenta was lying in the 
OS. It was immediately expressed but only after consider- 
able amount of force was used. Inspection showed it to be 
intact with all the membranes. Uterus relaxed a little and 
ergot was given intramuscularly. She was then washed up 
and put back to bed and she at once collapsed. Pulse be- 
came 160 and was almost imperceptible at the wrist. A 
hurried examination of the heart showed sounds to be clear 
and by percussion no dilatation was found. She was restless 
and of bad color. She was given at once an eighth of mor- 
phia subcutaneously. The pulse very shortly began to im- 
prove, she was quiet and the volume of the pulse became 
very much better. There was absolutely no bleeding from 



NORMAL PREGNANCY. 77 

the Uterus which remained hard. At 7:15 she vomited and 
again went to pieces. This time I gave her four ounces of 
black coffee and two ounces of water by rectum which she 
retained. I gave her subcutaneously 1/20 gr. of strychnia 
with 1/50 gr. of digitaHn. Her pulse gradually improved in 
character but the rate was 160. By eight o'clock pulse had 
dropped to no and she looked very much better though she 
still had marked pallor. There was no excessive flowing. 

From now on she improved in color. Pulse remained no 
and was of good quality. There was a normal amount of 
flowing and the uterus remained hard. The baby weighed 
seven pounds and four ounces. At ten o'clock as there was 
no nausea she was given a cup of hot broth which she re- 
tained and this was repeated in an hour. I left her at noon 
in good condition, pulse 100, temperature 100°. 

January 9. Very comfortable. Pulse no and of good 
volume. There is small amount of milk in the breasts and 
baby is to nurse once in four hours. Uterus at the umbili- 
cus. Is tender. Temperature is 99°. 

January 10. Uterus is one finger breadth below the 
umbilicus. Is well contracted and tenderness less marked 
than yesterday. Tenderness probably due to the fact that 
the uterus was held hard at the delivery and because of the 
force used to express the placenta. Temperature is normal 
and pulse to-day dropped to 80. Baby is satisfied on four- 
hour nursings. Patient's bowels were moved this morning 
by one ounce of castor oil. 

January 11. Temperature this evening 102.5°. Pulse 100. 
Breasts are tender and very full but without any lumps. 
Abdominal examination is absolutely negative. Baby is 
nursing well. 

January 12. Temperature 99°, pulse 80. Breasts less 
tender, but still full. Lochia normal. 

January 15. Temperature to-day is normal and pulse 70. 
She is looking very much better. Lochia is normal and the 
breasts now are soft and have come down to the needs of 
the baby. Uterus cannot now be felt above the symphysis. 
Started on her exercises to-day. Baby is doing well and 
gaining from two to four ounces every second day. Cord 



78 CASE HISTORIES IN OBSTETRICS. 

has not yet separated and is moist and has slight odor. 
Religated and powdered with subgallate of bismuth. 

January 21. Cord came off the day after it was religated 
and it left a large granulating base which was touched with 
the silver nitrate stick, wiped out with alcohol and then 
powdered. To-day it is very much smaller and is almost 
healed. 

February i. Patient got out of bed on the 29th. No 
prickling in her feet and no discomfort in her legs. Has con- 
scientiously carried out her exercises for the past ten days 
twice a day. There is no lochia. Baby's umbilicus is 
solidly healed and the nurse says it has been so for the past 
five days and that three days ago baby had a tub bath. 

February 24. Patient is now up and around the house, 
going downstairs as she wishes and out to drive. She is in 
excellent condition. Vaginal examination shows same stel- 
late tear of the first delivery, slightly relaxed outlet, slight 
tear on her right but on the whole a good perineum. Bear- 
ing down gives no bulging of the anterior or of the posterior 
wall of the vagina and the uterus is well involuted and 
normal in size and position. Nothing felt on the sides. 
The baby now weighs ten pounds and nine ounces and is 
nursing regularly. Bowels are moving two or three times 
a day, umbilicus is solid and there is no bulging. 



NORMAL PREGNANCY. 79 

Case 14. Primiparous Labor. Occiput Right Pos- 
terior. Patient is seen for the first time January 26th. 
She considers herself two and a half months along in her 
first pregnancy. She is twenty-two years of age, a large, 
robust, powerful looking girl. Her last menstruation oc- 
curred November 4th. It was at the usual time and lasted 
six days. Her menstruation began when thirteen years of 
age and lasts five days, never over six. Period comes every 
twenty-eight to twenty-nine days, occasionally she has been 
known to go thirty days. Seldom accompanied by pain. 
She comes at the present time because she has noticed that 
her urine is dark in color. Nausea is more marked in the 
evening than at any other period of the day. She gags a 
great deal but is never actively sick. What she belches up 
is not acid. Bowels move once a day without medicine. 
Her appetite is poor. She is very sleepy throughout the 
day. The breasts, she says, were tender to the touch at the 
time her first period was skipped but the tenderness is now 
gone. She has noticed that her breasts have enlarged con- 
siderably. She is drinking three glasses of fluid in the 
twenty-four hours. There is no change in the number of 
times she passes her water. Blood pressure no mm. of Hg. 
Specimen she passed in the ofiice was high in color, clear, 
specific gravity 1.026, no albumin or sugar. She was told 
to drink at least eight glasses of fluids in the twenty-four 
hours and to measure her twenty-four hour amount of urine 
which must be at least three pints. 

January 29. She brings in a specimen from the twenty- 
four hour amount of urine which was five pints. Examina- 
tion showed it to be pale, acid, specific gravity 1.004. Al- 
bumin and sugar absent. 

Since she has been drinking more water she has felt very 
much more comfortable. Much less nausea and she has been 
less sleepy. 

March i. She reports that for the last five days she has 
become more and more constipated so that for the last two 
days she had to take an enema in addition to the licorice 
powder she was taking every night. Because of this story 
of sudden increase of constipation I examined her by vagina 



80 CASE HISTORIES IN OBSTETRICS. 

at once. Uterus found in normal position, enlarged to the 
size of a three and a half to four months pregnancy. Noth- 
ing felt on the sides or in the posterior cul-de-sac. She was 
told to take two-grain tablet of cascara sagrada three times 
a day and if necessary two at bedtime. Blood pressure Ii8. 

July 23. She has reported once a month up to July. 
Urinary examinations have all been normal. The twenty- 
four hour amount is always about 2000 c.c. The blood 
pressure has never been over 120. She apparently is in ex- 
cellent condition. Palpation to-day shows small parts on the 
left with smooth resistance on the right. Head is freely 
movable at the brim. Baby now lies in a right position. 
Fetal heart is heard in both right and left lower quadrants, 
128 to the minute. Her pelvis measures, crests 30 cm., 
spines 26.5 cm., external conjugate 20.5 cm. 

August I. Vaginal Examination: — The biparietal is 
just engaging at the brim but the head can be readily pushed 
up. Promontory cannot be reached. Ischial spines are not 
prominent. Inclination of the pelvis is normal and the 
pubic arch is normal. Bi-ischial diameter with Williams's 
pelvimeter 10.5 cm. Cervix is very soft and os uteri admits 
one finger and is flush with the vaginal vault. On the ex- 
amining finger an unusual amount of blood came away but 
nothing abnormal was felt. 

August 2. At 12:50 P.M. the patient telephones that she 
"was flooded.'* I told her to go to bed at once and I would 
come immediately. I found her in bed and examination 
showed simply that the membranes had ruptured. There was 
no bleeding and she was having no pains. At half-past one 
while I was there she had her first contraction. Palpation 
showed the head firmly fixed at the brim but the biparietal 
diameter was not through the inlet. Fetal heart 130 and 
regular. From then on the pains came every ten minutes 
and at half past three they began coming every three min- 
utes. Palpation shows that the head has appreciably de- 
scended into the pelvis. No bleeding. Small amount of 
liquor coming away. She is now in very active labor. 
Fetal heart is 140 in the right lower quadrant. ' She was 
ahead of the reckoned time and after some difiiculty a nurse 



NORMAL PREGNANCY. 8 1 

was obtained. When examined at quarter-past four she was 
found to be fully dilated and head was on the perineum. 
Posterior fontanelle was readily distinguished in the antero- 
posterior diameter just behind the symphysis. Pains now 
were very hard and were coming every three minutes. She 
was at once given obstetrical ether. At 4:30 she began to 
bulge the perineum perceptibly and was bearing down with 
each pain. At quarter of five put in the side position and 
everything was ready for delivery. With each pain she 
worked well and with the obstetrical ether was comfortable. 
At five o'clock the scalp appeared at the vulva and the circu- 
lation was good. With each pain the ether was forced. The 
baby was born at 5 :30 p.m. The head restituted to right pos- 
terior position. Shoulders were delivered very slowly and the 
body came along without any difficulty. Baby cried at once 
and the cord when it stopped pulsating was clamped and cut. 
Uterus acted well and there was no bleeding. Baby was in 
excellent condition. Patient was then turned on her back 
and the placenta came away seven minutes after the de- 
livery spontaneously. Examination of the placenta showed 
it to be intact with all the membranes. Careful examina- 
tion of the perineum showed absolutely no tear. She was 
cleaned up and sterile pad put on. Put back to bed with 
pulse of 80 which steadily dropped and one half hour after 
delivery was 68. There was a slight ooze from the uterus 
and it had a slight tendency to fill up, but with careful 
holding it soon acted well. No ergot was given. At no 
time did the pulse go over 80. Baby weighed 7 pounds and 
12 ounces. Left the patient at seven o'clock in excellent 
condition with the usual orders to the nurse. 

August 3. Uterus hard, three finger breadths below the 
umbilicus. No tenderness over the uterus. Lochia normal 
in amount. Breasts have a slight amount of colostrum in 
them and the baby is to be put to the breast every four 
hours to-day. Baby last night had a great deal of mucus 
and twice it had to be held up by its heels and drained. 
Temperature is normal, pulse 75. Mother to be given half 
an ounce of castor oil early to-morrow morning. If neces- 
sary, to follow it with an enema three hours later. 



82 CASE HISTORIES IN OBSTETRICS. 

August 4. Telephone from the nurse that the bowels 
moved well this morning and patient is in excellent con- 
dition, that the lochia is slight in amount but normal in 
color. Late this afternoon telephone from the nurse saying 
there has been no lochia since one o'clock, that the tem- 
perature is normal and the pulse 80. Nurse told to put hot- 
water bag over the uterus and if the lochia did not start up 
in the course of an hour to turn the patient over on her 
abdomen in order to favor drainage. 

August 5. Telephone from the nurse that the lochia 
started up half an hour after the hot- water bag was placed 
on the uterus and that now it is profuse and red, with no 
odor. Temperature is normal. Pulse is 70. Milk is com- 
ing in and baby is now on two-hour feedings. 

August 23. Patient has made an absolutely normal con- 
valescence. Temperature has been 98.6° and the pulse has 
varied from 70-80. The patient is very languid and is un- 
willing to exert herself. She began her exercises on the 
fourteenth day and did them faithfully. On getting out of 
bed to-day, the twenty-first day, she had relatively small 
amount of "pins and needles.'* There is no vaginal dis- 
charge present. The baby is doing well and now weighs 
eight pounds and twelve ounces. 

September 13. Baby has been put on one bottle a day 
of home modification, made up from certified milk, of a 
2.50% fat, 6.00% sugar and 1.00% proteid. The patient is 
doing more and more about her house, is out walking and 
driving and is steadily improving. Vaginal examination to- 
day shows no discharge. No tear of the perineum. Cervix 
has a very slight bilateral tear. Uterus normal in position 
and freely movable. Nothing present on the sides. Baby 
has done uniformly well. Umbilicus is solidly healed and 
there is no bulging. Case discharged. 



Summary of Normal Pregnancy. 

The prenatal care that the average physician gives a 
pregnant woman is appallingly little. The blame for this 
condition of affairs lies to a great extent with the teaching of 



NORMAL PREGNANCY. 83 

obstetrics in the majority of medical schools (Williams, 
Journal A. M. A., Vol. 58, No. i, p. i). 

The laity regard childbearing as a normal physiological 
act and take it for granted that nothing can go wrong. 
Pregnancy may be normal, but there is no physiological con- 
dition which verges so often, and so quickly, upon the patho- 
logical. 

Because this is an established fact the need of intelligent 
medical care of the pregnant woman is essential. As ad- 
vance in obstetrics has been made, this preventive care has 
been more and more insisted upon and the better the phy- 
sician the more care he gives his obstetric case. There is no 
branch of medicine where a disastrous result may occur that 
does the physician's reputation so much damage as a dis- 
aster in obstetrics, and it behooves all medical practitioners 
who do obstetrics to do it well or to let it absolutely alone. 
To the careless, inefficient man disaster surely will come; 
possibly such an occurrence is the only thing that will arouse 
such a man. 

When a pregnant patient places herself under a phy- 
sician's care he must discuss with her what can be called 
the hygiene of pregnancy. Each physician will develop his 
own method. Many obstetricians have a printed slip which 
they give each patient with the fundamental facts. Whether 
one adopts this way or simply talks to the patient is im- 
material but the various points must be covered concisely, 
in plain words, avoiding carefully all medical terms. 

The Children's Bureau of the United States Department 
of Labor has recently issued a most valuable pamphlet 
on Prenatal Care. It can be obtained for the asking by 
writing to the Children's Bureau. In large clinics this 
pamphlet can be given to each new patient and great good 
should result from it. Davis's '* Mother and Child" and 
Slemons's "Prospective Mother" cover more fully than is 
possible in a small pamphlet the necessary points that a 
pregnant woman should know and with many patients in 
private work great help comes from their having one or the 
other of these two excellent books. 

One must go over with each patient her previous history 



84 CASE HISTORIES IN OBSTETRICS. 

both as regards her health and also the character of her 
previous pregnancies and labors if she is a multigravida. 
Her menstrual history must be determined and the be- 
ginning of her last menstruation carefully noted. In all of 
the cases here recorded, I have not put this down because 
of obvious reasons, but in all cases these facts were de- 
termined and recorded. The reckoning of the date of labor 
is most unsatisfactory and of all the ways suggested, I have 
found in my practice that if one takes the first day of the 
last menstruation, counts back three months and adds ten 
days, that the date thus obtained is as close as can reason- 
ably be expected. I then tell all patients to be ready for 
their labor at least two weeks before this date and that 
they may expect to be delivered a week before or after 
this date. Never make one date and allow your patient to 
think that if she goes beyond this date that she is going 
over time. The possibility of mistakes either way are too 
great; a labor two weeks before or after the suggested day 
is so common that nothing is thought of it. Find out if the 
patient knows that pregnancy could not have begun until 
two weeks, even three weeks, after a period and in these 
cases reckon from this time and not the period. (Case 17.) 

The histories of the previous cases show briefly the care 
that should be given pregnant patients. In all of the above 
cases I have not recorded each and every visit that the 
patient made, grouping some and omitting others, bringing 
out one point in one case and a different one in another. 
Now let us go over the various points one by one. 

The bowels must move once a day. If they do not do so 
naturally, a mild cathartic, such as cascara, compound lico- 
rice powder or phenolphthalein, must be used. Each patient 
must determine the dosage necessary. Even if the bowels 
move of themselves daily, sometimes the evacuation is not 
sufficient as was seen in Case 9. In the last two months of 
pregnancy it is best always for the patient to take, once a 
week at least, a cathartic to clear out thoroughly the in- 
testinal tract. This is especially true if the patient is con- 
stipated and relying on enemas alone to obtain a dejection. 

The urine should be measured once a month from the 



NORMAL PREGNANCY. 85 

sixth month at the latest and the twenty-four hour amount 
must be three pints, or more. In order to obtain this amount 
fluids must be freely taken. Water is the best. Case 14 
came first to the office because she had noticed that her 
urine was "dark." As soon as she began to drink more 
water her nausea and sleepiness became less and soon dis- 
appeared. The patient should send to the office a specimen 
of the mixed twenty-four hour amount of urine once a month 
from the fourth month and earlier if there is the slightest 
sign of toxemia present. From the sixth month the urine 
should be examined every two weeks until delivery. The 
examination of the urine consists in noting its color and 
amount of sediment, taking the specific gravity and reaction 
and determining the presence or absence of albumin by the 
nitric acid or heat test. If there is more than a slight trace 
of albumin present, more accurate estimation of the amount 
is obtained by using Esbach's albuminometer. On testing 
the urine for sugar, if a reduction by Fehling's solution takes 
place it is not sufficient evidence that glucose is present. 
Lactose also gives a reduction with Fehling's. If reduction 
takes place, then the fermentation test for glucose must be 
done; and if positive, then sugar can be said to be present in 
the urine. The use of Fehling's test alone has given rise to 
much unnecessary alarm. If a true diabetic condition ex- 
ists coincident with pregnancy, then the patient must be 
treated for the diabetes. The pregnancy becomes of second- 
ary importance. If a transient glycosuria is present, no 
anxiety need be felt. Not a few pregnant patients show 
this condition and if their sugar intake is reduced the sugar 
quickly disappears. It is not a true diabetic condition and 
care must be taken not to disturb these patients without 
sufficient cause. 

If albumin is present, then a careful microscopic exami- 
nation of the sediment must be done and the findings care- 
fully noted. In specimens of urine recently passed which 
do not filter clear, a microscopic examination should be 
done for the sediment may show that a cystitis or pyelitis 
is present. (Case 62.) gj 

Many patients in the last six weeks of pregnancy show 



86 CASE HISTORIES IN OBSTETRICS. 

slight traces of albumin without any untoward symptoms. 
In such patients the most careful watch must be kept. 
Blood pressure observations combined with frequent urinary 
examinations will show impending toxemias before any 
other symptoms arise. Every patient should have her blood 
pressure taken at each visit she makes to the office. If it is 
found normal, 120 mm. of Hg., there is little chance that 
a toxemia is present. But if the pressure is found to be 
gradually rising, a toxemia is beginning and treatment must 
be begun. The treatment is taken up under the cases show- 
ing the toxemia of pregnancy. 

The patient may eat anything she can digest ; a full varied 
diet with fruit is the best. Up to the last two months I do 
not limit the diet unless there is some positive indication, 
but from then on I ask the patient to limit the amount of 
her carbohydrate food with the hope of obtaining a smaller 
baby than if she were on a large carbohydrate diet. 

The amount and character of exercise a patient may take 
during her pregnancy depends entirely upon what she has 
been accustomed to. If she has been in the habit of play- 
ing golf and tennis and plays the games well, she naturally 
will not want to be held down to playing a slow, careful 
game. The result will be that she probably will not play 
them at all during her pregnancy and on the whole it is 
very much safer that she should not. If there has been any 
question of abortion or premature labor all athletic games 
must be interdicted absolutely. Walking is much the best 
exercise that she can have. It must not be done to over- 
fatigue. If a patient has been out walking and comes back 
feeling tired and does not become rested in the course of 
half or three-quarters of an hour there is no question but 
that she has done too much. A patient's household duties 
will oftentimes be all that she can do and be not over-fa- 
tigued. The patients themselves must find out what the 
limit of their endurance is and be guided by it. The amount 
of exercise must be restricted at what would be a menstrual 
period were the patient not pregnant. In many cases, how- 
ever, it is impossible to tell when a period would come but 
in many others the patients unquestionably feel the time of 



NORMAL PREGNANCY. S^ 

the menstrual wave and at these times they must be quiet 
and avoid all but the most necessary exercise. 

In recent years the general use of the automobile has 
brought with it many dire results to pregnant patients. 
Case 8 was a typical example of automobile miscarriage. If 
patients are going in automobiles it is much safer for them 
to sit in the front seat where the vibration is less than on the 
back seat. If they use an automobile they must not go 
more than fifteen miles an hour on the smoothest of roads 
and if the road is rough they must go at the slowest possible 
rate of speed. The distances must be short and they must 
never go on long continuous rides. Careful use of the auto- 
mobile is one of the best ways for a pregnant patient to 
obtain fresh air, but used to the extremes that some phy- 
sicians sanction I am confident it is a potent cause of mis- 
carriage. Observations have not been noted long enough 
to know whether excessive automobiling will give abnormal 
positions or whether the umbilical cord is entangled in a 
larger per cent of cases, when there has been much riding, 
than in those where there has been none. It is conceivable 
that by the constant motion that the fetus is subjected to, 
it may, in the early months when floating in the liquor amnii, 
become so entangled that intra-uterine death may follow. 

As soon as the pregnancy is known to have begun the 
patient should go to a dentist to have her teeth put in the 
best possible condition. No long painful work should be 
done at any one time. Short appointments should be 
sought and the work done as painlessly as possible. Tempo- 
rary work sometimes will be perfectly satisfactory. The old 
saying ''for every child a tooth" is at the present time abso- 
lutely unwarranted, and is due to the carelessness of the 
medical attendant. It was only very recently that I had the 
obstetric care of a patient who was under another physician's 
care during her pregnancy. She had complained to him 
that her teeth were paining her and that one or two fillings 
had come out but he absolutely forbade her to have anything 
done to her teeth while she was pregnant for fear of an 
abortion. The result now is that whenever she chews her 
food there is pain in her teeth and every little while she is 



88 CASE HISTORIES IN OBSTETRICS. 

disturbed by their aching. Surely such a condition is a 
great reproach upon the medical attendant. If the patient 
at any time during her pregnancy is having a great deal of 
acid eructation, the enamel of her teeth will be preserved by 
rinsing the mouth and brushing the teeth in an alkaline solu- 
tion. Milk of magnesia as in Case 13 has proved very 
satisfactory. 

The skin must be kept active by daily warm baths. Avoid- 
ance of extremes of hot and cold is important. Patients 
who have always been in the habit of taking a cold bath in 
the morning can with safety continue provided they react 
well. The same remark is true about patients going in 
bathing. There is no reason why they should not go in 
swimming if they react well on coming out, but if they do 
not, bathing must not be indulged in. The vulva must be 
carefully cleansed each morning and night because of the in- 
creased amount of secretion that may be present during 
pregnancy. Unless there is some pathological condition 
present, douches are absolutely contra-indicated. 

The dress of a patient is important for the physician to 
take note of. There must be no compression around the 
waist; the abdomen must have free chance to enlarge. As 
few bands as are possible should be around the waist. The 
principle for a pregnant woman to remember is that all 
clothes that can must hang from the shoulders. For the 
first three or four months ordinary corsets may be worn 
with safety provided the patient is willing to let them out 
according to her increase of size. What maternity corset 
she buys will be a personal matter to a great extent. One 
dealer's make will be perfectly satisfactory to one patient 
and be absolutely uncomfortable for another. If the abdo- 
men is pendulous oftentimes an abdominal support will give 
the greatest relief. 

Physicians vary greatly in the care of the breast during 
pregnancy. Some recommend using astringent washes dur- 
ing the pregnancy. Others leave them entirely alone. I have 
never used astringent washes. Ordinary cleanliness of the 
nipples is sufficient and if dry scales come, during any time 
of the pregnancy, they can be readily softened by lanoline 



NORMAL PREGNANCY. 89 

and then washed off. I have had consistently good results 
by having the patients let their nipples entirely alone until 
after the confinement is over. Occasionally one or both 
nipples become tender to the pressure of the patient's clothes. 
Here a simple ointment applied freely or an ointment of 
5% orthoform in lanoline will help the condition materially. 
In the early months of pregnancy, when the patient is wear- 
ing her usual corsets, she should be warned not to have them 
come so high that they can in any way press on the breast 
tissue. This point is especially to be impressed on the 
patient during the nursing period, for if the breast at this 
time is pinched, serious complications may follow. 

During the last months of pregnancy, in the patients who 
have inverted nipples, a warm bottle may be put on the 
nipples each night at bedtime for ten minutes. An eight- 
ounce nursing bottle thoroughly cleaned is warmed with hot 
water, the water poured out and then the bottle inverted 
and the mouth put over the nipple. The hot air inside the 
bottle gradually cools and a vacuum is established, and the 
nipple is drawn up into the neck of the bottle. I prefer this 
method to the advice sometimes given to the patient to pull 
out the nipples with her fingers. A miniature breast pump 
designed especially to pull out the nipples may be used if it 
can be obtained. As yet it is not widely carried by supply 
houses and it offers no great advantages over the bottle. 

The question of sexual intercourse during pregnancy is 
oftentimes troublesome. No matter what advice is given it 
often is not followed. All physicians will probably agree 
that if there has been any tendency to abortion there must 
be no intercourse under any circumstances. Intercourse in 
what would be a menstrual period were the patient not 
pregnant is to be avoided. There is no question that in the 
majority of cases intercourse is indulged in during pregnancy 
and it apparently does no harm. The object of intercourse 
has been accomplished when pregnancy begins and ideally 
there is no reason for more, but the ideal is seldom obtained. 
Many patients have a marked aversion to intercourse the 
moment they become pregnant. Some tell of a pregnancy 
because of this aversion. On the whole, I think physicians 



90 CASE HISTORIES IN OBSTETRICS. 

have sanctioned intercourse during pregnancy to too great 
an extent. During the latter months of pregnancy un- 
questionably damage may be done and infection may follow 
especially if labor should start shortly after intercourse. 

The patients should be seen once a month during the 
first six months. They must be told that throughout their 
entire pregnancy they must be well. If they notice any- 
thing out of the ordinary, if their bowels are not moving 
well, if their urine is becoming less in amount or darker in 
color or if they are having any headache or if there is any 
sign of blood from the vagina, they must report at once to 
you. They are to accept no responsibility, they are not to 
determine whether any sign or symptom is unimportant. 
Make it clear that unless they are willing to report at once 
the slightest unusual symptom you will not undertake to 
look after them. By your seeing the patients monthly you 
come to know their characteristics, how they stand the dis- 
abilities which necessarily come with pregnancy. You know 
their mental poise and their physical limitations all of which 
help you in determining how each individual patient will 
stand her labor. During the last three months besides re- 
porting at the office the first of each month, and bringing 
with them a specimen, I require all patients to send in a 
specimen on the fifteenth of the month. By this means I 
am in touch with them every two weeks. This is the ordi- 
nary routine; any case may vary. If anything untoward 
comes up, then the routine is altered to suit the emergency. 

Theoretically, all patients should be examined by vagina 
as soon as they present themselves to you for care during 
their pregnancy in order to rule out an abnormal condition 
in the pelvis. Practically few cases are now examined at the 
first visit ; each year I examine at once more and more cases. 
I intend to, and think all cases should be. In many cases 
it may not be a necessity; in a few some pathological con- 
dition will be found that demands surgical intervention. 

In not a few cases the uterus will be found retroverted or 
retroflexed. When it can be replaced without difficulty it 
should be and a pessary fitted to hold it in position until the 
fundus has so enlarged that it cannot again fall back into the 



NORMAL PREGNANCY. QI 

posterior cul-de-sac (Case 68). If the uterus cannot be re- 
placed with gentle manipulation without ether, then two 
courses are left open, either to etherize the patient and then 
replace and hold the uterus in position by a pessary or to 
have the patient report every two weeks so that the position 
of the uterus as it enlarges may be followed. If this latter 
course is determined upon then the patient should be shown 
how to put herself into the true knee-chest position. She 
should get into this position morning and night and should 
have no encircling bands about the abdomen when in posi- 
tion. A few long inspiratory breaths will help a great deal to 
balloon the vagina and aid the uterus to return to its nor- 
mal anterior position. This latter course is the conservative 
one and should at the outset be tried, reserving the etherizing 
of the patient until one is convinced the knee-chest position 
will not bring the uterus up into position. Care must be 
taken not to allow the uterus to become so large in the re- 
troposition that it will become incarcerated. 

The pelvis should be measured in all primigravidae by the 
eighth month; earlier measurement is not necessary. I do 
not measure multigravidae who have had average sized 
children with no difficulty. If the history, however, of pre- 
vious difficult deliveries is obtained then they too should be 
measured. 

The external measurements to be taken are the inter- 
cristal, the inter-spinous, the external conjugate, and the 
bis-ischial diameter of the outlet and the normal are in centi- 
meters, respectively, 28, 25, 20 and 11. 

The pelvimeter one uses must be tested on an accurate 
scale for many pelvimeters which are for sale are inaccurate 
and if one relies entirely on these measurements he may 
find himself in serious difficulty. 

The inter-cristal and inter-spinous measurements are taken 
with the patient lying on her back with no clothing be- 
tween the pelvimeter and the skin. The external conjugate 
is readily taken if the patient is in the right position. For 
this she should be lying on her left side, back to the phy- 
sician, lower thigh flexed with the upper leg straight. By 
this position the physician can readily palpate the depression 



92 CASE HISTORIES IN OBSTETRICS. 

midway between the posterior superior spines and place 
directly one arm of the pelvimeter with the left hand on it. 
With the right hand he places the other arm directly on the 
symphysis and then reads from the scale the distance. I 
usually do not measure the outlet until I make the vaginal 
examination, sometime in the last month of pregnancy. 

Each year I am. coming to rely upon these external 
measurements less and less. I take them for a guide, noth- 
ing more. They are of interest and help one to make up 
one's mind as to the probable outcome. The real test is the 
relation of the baby that is in utero to the given pelvis; the 
mere size of the pelvis unless it is actually an impossible 
one, and that occurs very rarely, is of little value unless the 
size of the baby is known. Much has been written about 
the measurements of the pelvis ; less has been said about the 
relation of the baby to the pelvis and it is upon this that 
the successful issue of a case depends. 

The methods of palpation can be given in writing, the 
proper interpretation of what one finds by palpation comes 
only after large experience. Every patient should be care- 
fully palpated. The beginner will many times be completely 
baffled, but by constant practice with intelligent thought of 
the problem in hand, steady and marked improvement will 
come. 

About four weeks before the expected date of delivery, it 
may be in some cases a little earlier or later, careful pal- 
pation of the abdomen should be done. It is my custom 
usually to see the patients for this purpose in their own 
homes. They should be undressed lying down in bed. 
The abdomen should be bared from ensiform to pubes. 
The physician stands or sits on one side of the bed or the 
other, facing the patient. Usually I elect to be at the 
patient's right. The hands, warm and clean, are then put 
on either side of the abdomen, palms downward, fingers 
slightly separated and flexed. The hands are now gently 
rolled over the abdomen slowly and deliberately with but 
slight pressure. One very soon begins to appreciate the 
differences in the resistance beneath the abdomen. A 
smooth, firm mass on the one side with slight irregularities 



NORMAL PREGNANCY. 93 

on the other, means necessarily a back, and the small parts 
opposite. With a back on the left, the position necessarily 
becomes a left one. 

For the second manoeuvre, or grip as the English call it, 
the hands are moved up to the fundus — surrounding it, 
cupping it, the finger tips towards the middle line and then 
the outline of what is at the fundus made out. The breech 
runs into the back which has already been determined and 
it moves with the back, i.e., there seems to be a definite 
continuity. If the head is in the fundus it moves slightly 
without motion in the back. The head is hard and more 
round than the buttocks. If it is the head, ballotment can 
usually be obtained which cannot be obtained with the breech. 
Ballotment is obtained by sudden tapping or pushing the 
part in the fundus downward and then quickly taking off all 
pressure and with the fingers yet on the abdomen waiting 
to see if the part is felt to rise beneath the finger tips. 

For the third grip the thumb and middle and forefingers of 
the right hand seize whatever is just above the pubes and 
by gentle side-to-side motion one determines whether it is 
firmly fixed in the pelvic brim or whether it is freely mov- 
able at the brim. The contour of the part is soon appre- 
ciated and whether it is a head or a breech may be determined. 

For the fourth grip the physician turns about and faces 
the patient's feet and with the three middle fingers of each 
hand on each side of the presenting part he forces them 
downward along this part and then notices the relationship 
of the fingers of the left hand to those of the right. (For a 
specific example take Case 13, page 75, also page 109.) 

If we find by palpation that the presentation is vertex 
and the head well engaged in the pelvis all worry about the 
inlet of the pelvis is over and the outlet alone remains to be 
determined. If, however, we find the presenting part freely 
movable a month to two weeks from labor the size of the 
inlet must also be determined and that is best done by a 
vaginal examination. 

From these manoeuvres a physician may learn much about 
the fetus. The beginner will make many mistakes. No 
one can palpate too often, for from each case something new 



94 CASE HISTORIES IN OBSTETRICS. 

may be learned. Gradually, as one becomes proficient the 
size of the fetus may be closely estimated. This is the im- 
portant point, — to be able to estimate accurately the size 
of the fetus that has to pass through the given pelvis. If 
the presentation is a vertex the relation of the baby to the 
pelvis may be fairly accurately surmised, but if the breech 
presents, the relation of the head is much more difficult to 
determine and the liability of error is much increased. 

During palpation of the abdomen fetal motion very prob- 
ably has been obtained and this is proof positive that the 
child is alive. Before proceeding to any further examination 
of the patient, listen to the fetal heart and count accurately 
its rate and record it, for if you know what it is before labor 
it may help you much during labor. (Case i6.) In left 
positions and a vertex presenting the fetal heart is usually 
best heard in the left lower quadrant and in the right lower 
quadrant in right positions. If the breech is presenting the 
fetal heart usually is above the umbilicus to one side or the 
other as the position may be. The position, however, is 
never determined by the location of the fetal heart alone. 
The fetal heart is located in order to follow the child's con- 
dition, never to settle its position in utero. 

A vaginal examination is now made to examine the pelvic 
cavity and the outlet of the pelvis. If the presenting part 
is not already in the pelvis an examination of the inlet is 
made. For this examination the patient is best placed across 
the bed, buttocks at the edge of the bed with legs flexed, feet 
resting on a chair placed directly in front of the patient. 
If this examination is made within a month of the expected 
labor the vulva must be carefully scrubbed up. The ex- 
amining hand, usually the left, should be clean and a sterile 
glove worn. No lubricant is necessary and it may be said 
in making any vaginal examination a lubricant is totally 
unnecessary. In making this examination certain condi- 
tions are to be noted and it is best for the beginner to follow 
some one method so that all necessary points may be covered. 
The following scheme has worked well in my hands : 

I. The size of the introitus, and the amount of secretion 
and its character. 



NORMAL PREGNANCY. 95 

2. The condition of the perineum, whether it is rigid or 

soft; the presence or absence of tears. 

3. The position, size, shape and consistency of the cervix. 

4. Whether the presenting part is in the pelvis or not. 

This point has already been determined by the fourth 
manoeuvre in palpating and the findings are now 
simply confirmed. The height of the presenting part 
is noted. 

5. If the presenting part is not in the pelvis an attempt is 

made to reach the promontory of the sacrum. Be- 
fore one attempts this the patient should know that 
he may hurt her and she will in the majority of 
cases not flinch. This measurement is by no means 
easy to obtain accurately unless the patient is under 
ether. It usually is a negative finding, that is, the 
promontory is not reached. The method of taking 
it is to insert the index and middle fingers of the left 
hand as far upward as one can reach with the hope 
that the middle finger will reach the promontory. If 
it does, then the point on the index finger between 
the thumb and index finger which is directly under 
the symphysis is held with the right hand and this 
distance (from the tip of the middle finger to this 
point) measured. If this measurement is taken it is 
best not to do it until the last, after all the other 
points enumerated below are noted; otherwise, it 
will necessitate making a second unnecessary exami- 
nation. 

6. The contour of the inlet is palpated. No one can teach 

the interpretation of what is felt; it comes with ex- 
perience. One palpates many normal inlets and when 
an abnormal inlet is found one has trained himself so 
well that one appreciates any difference. 

7. The contour of the pelvic walls and the spines of the 

ischia. The interpretation of these points comes also 
by experience and is difficult to write about. In prac- 
tically all cases can the spines be palpated and when 
they are very prominent it is very suggestive that the 
head may be held up there at delivery and a forceps 
operation be necessary. 

8. The amount of motion present in the coccyx. Case 17 

is a good example of where the coccyx gave difficulty 
in the delivery. 

9. The condition of the rectum, whether it is full or empty. 
10. The height, thickness and inclination of the symphysis 

is important. 



96 CASE HISTORIES IN OBSTETRICS. 

If the presenting part is not engaged and is a vertex, be- 
fore the fingers are withdrawn from the vagina seize the 
head between the thumb and forefinger of the right hand and 
attempt to push it down gradually into the pelvis. With 
the internal fingers note how low the head comes down and 
at the same time place the thumb of the left hand at the 
symphysis and note whether there is any overriding of the 
head at the symphysis. I shall take this point up again, 
later, in relation to contracted pelves but it is a point which 
should be carefully carried out whether there is any con- 
traction present or not. 

11. The fingers are now withdrawn and the angle of the 

symphysis determined. This is best measured by 
placing the tips of the thumbs together at the middle 
of the angle and letting the inner surface of the 
thumbs lie along the descending rami of the pubes. 
In this way one can see very readily what the angle 
of the symphysis is. 

12. The bis-ischial diameter is measured last. For this 

purpose Williams's pelvimeter is very useful. If you 
have not made yourself familiar with its use you can 
make yourself efficient by knowing the size of your 
own closed fist. Place the closed fist between the 
ischial tuberosities; by a rocking motion one very 
readily comes to estimate quite accurately whether 
the outlet is contracted or not. 



The Physician's Outfit. 

The physician's outfit for obstetric work varies; from an 
outfit which I saw some years ago consisting of an old pair 
of forceps with wooden handles, a rusty pair of scissors, and 
an empty ergot bottle, to what the obstetric specialist of 
to-day carries, which makes it possible for him to do most 
of the major obstetrical operations. The necessary instru- 
ments, however, are as follows: 

A pair of Simpson forceps One rat-tooth forceps. 

with axis traction rods. One pair of scissors. 

Four hemostats. One needle holder. 

One smooth forceps. Perineal and cervix needles. 



NORMAL PREGNANCY. 97 

Two French hooks. Catgut of assorted sizes, 
Intra-uterine douche nozzle, plain and chromicized. 

Silk worm gut. Bobbin. 

Safety razor. Two pairs of rubber gloves. 

All physicians know that in many cases the number of in- 
struments they will use in a normal delivery may be few, but 
there is no physician who can foretell what case is going to 
be normal or when a serious complication may occur. For 
that reason every man who wishes to be regarded as doing 
obstetrics well must carry enough instruments with him so 
that he can deal intelligently with all of the ordinary emer- 
gencies. 

For the physician's own convenience a small copper 
sterilizer of sufficient length and height to hold the forceps 
should be in his bag, for in many houses one cannot find a 
vessel of sufficient length to hold the forceps unless it be so 
large that much time is consumed in boiling the water it 
contains. In this the instruments are boiled just before 
needed and left in it until used. Any obstetric case may 
have a severe hemorrhage, therefore a subpectoral needle 
or an intravenous cannula, with the necessary rubber tubing 
connections, funnel or a douche bag, and salt solution tab- 
lets, must be in the bag. In more recent years I have 
carried a salt solution outfit which various surgical sup- 
ply houses now have for rental at a nominal price. This 
outfit contains a flask of two quarts of sterile salt solution, 
with rubber tubing and a sterilized subpectoral needle, all 
contained in a wooden box, making transportation easy and 
safe. Besides the above instruments the following articles 
are necessary: 

One large rubber apron. Hypodermic syringe. 

Nail brush. Ether. 

Mouth gag. Leg holder. 

Rectal tube. Alcohol, 70%, one quart. 

I further carry on all cases the following sterile goods: 

A gown with long sleeves. 

A sheet. 

A package of half a dozen towels. 



98 CASE HISTORIES IN OBSTETRICS. 

At least two packages of gauze sponges, 4 inches by 2 
inches, and a five-yard strip of gauze uncut, for packing 
the uterus. j 

If the patient can afford it have her nurse order these 
sterile goods from a supply house. What are soiled are 
sent back dirty and a charge is made. For what is not 
used credit is allowed. Other sterile goods are needed but 
they will be referred to later in the mother's outfit. 

The drugs that are necessary are: 

Corrosive sublimate tablets of the usual strength, one 
tablet to a pint of water making i-iooo solution. 

Ampoules of aseptic ergot, for subcutaneous use. 

Ampoules of pituitrin or hypophysin. 

Hypodermic tablets of strychnia and morphia of varying 
strengths, and what other stimulating drugs you believe in. 

I have purposely omitted in this list the Kelly pad, for I 
firmly believe it is a source of infection and a bed pad that 
can be made up before the onset of labor by the patient or 
by the nurse serves the purpose as well and is many times 
more clean. 

For the physician who goes to an obstetric case with only 
a pair of dirty hands this list is a formidable one, but no 
physician who is conscientiously trying to do good obstet- 
rics can afford to carry any less. He may have to use, as 
we all know, but a few things in the above list. He may 
have to use them all and if he has not them with him when 
he needs them there is no time to send for them. He will 
be grossly negligent if he does not carry with him everything 
that he can possibly need. The slipshod manner in which 
some physicians manage an obstetric case is nothing short 
of criminal and it will be a relatively short time before the 
laity are educated to the point where a physician must be 
as prepared to manage an obstetric complication as a surgeon 
is to meet a surgical emergency. If a physician poses as a 
consultant in obstetrics he must add to the above list a 
cranioclast, a mechanical dilator, a blunt hook, and a set of 
rubber dilating bags with an eight-ounce metal syringe to 
fill them. Besides this list I carry a ribbon retractor and a 
large size Sims' speculum, both of which have been very useful 



NORMAL PREGNANCY. 99 

more than once in repairing lacerations. This list is ade- 
quate except for a Caesarean section or a pubiotomy. I 
strongly advise physicians to have their own instruments 
and use only their own and not rely on those of other phy- 
sicians or of the hospital where they may occasionally operate. 

The Mother's Outfit. 

The patient will ask what are the necessary things to have 
in readiness for her approaching confinement. You must 
know them, and you must not be extravagant but you must 
have the things you need. The following list is one that 
has proved satisfactory to me for some years. There is no 
question but that you can do obstetrics and do it aseptically 
without any such list as this. What will be bought will 
depend entirely upon how much money the patient has to 
spend. You cannot do obstetrics well unless you are clean; 
that is certain. Many things in this list are a pleasure to 
have on an obstetric case, but a patient will make a per- 
fectly good convalescence without them: 

Alcohol, I quart (95%). Fountain syringe (2 quarts). 

Boric acid crystals, J lb. Hot water bottle. 

Tr. green soap, 8 oz. Rubbersheetingto cover bed. 

Squibbs ether, 2 (| lb.) cans. Rubber sheeting, i yd. 

Lanoline, i tube. square. 

Vaseline (white). Safety pins, 4 doz. size 4 

Absorbent cotton (2 lbs.). Safety pins, 2 doz. size o 

Glass drinking tubes (2). Some way of heating drinks 

Nail brushes, 2 (5 cents each). at night. 

Orange wood sticks (2). Old blanket. 

Enamel basins (2), 11 inches Old linen and cotton. 

in diameter. Paper bags. 

Enamel basin (i), 18 inches 4 binders 18 by 45 inches (6 

in diameter. yds. unbleached cotton). 

Pails with covers (2). Tape, |-in. wide, one roll. 

Douche pan. i pr. white stockings. 

Sterile Goods, 

Sterile obstetrical package. 2 packages towels (6 in 

package). 



100 CASE HISTORIES IN OBSTETRICS. 

Explanations are needed for this list. I ask for crystals 
of boric acid rather than the powder because a saturated 
solution can be made up very much more readily from the 
crystals than from the powder. If you believe in having 
chloroform on an obstetric case rather than ether you ask 
for the chloroform. The recent work on delayed chloroform 
poisoning aside from the danger, has made many give it up 
entirely. If the patient does not wish to buy the enamel 
basins, basins in her household can be used, provided they 
are carefully cleaned and sterilized before use. The pails 
with covers are used after the delivery for the baby's nap- 
kins. A douche-pan is as satisfactory as a bed-pan and can 
be used on occasions after the delivery, more readily than 
can a bed-pan. Two sizes of safety pins are necessary and 
what kind you get is immaterial as long as they do not bend 
and will go through the diapers and the binders. The 
nurse will appreciate some way of heating the drinks at 
night that will obviate going down two or three flights of 
Stairs to the kitchen. The old linen and cotton are used for 
the baby and for the mother. For the mother linen squares 
of two inches are cut to put over the nipples and to keep 
the lanoline on them. Immediately after birth, linen is put 
beneath the baby's buttocks in order to catch the meconium. 
The paper bags are asked for so that the nurse can drop the 
soiled pads into the bags and then carry them down to the 
furnace to be burned. If you ask your patient to buy six 
yards of unbleached cotton it can be cut into four binders 
eighteen by forty-five inches. These binders should not be 
hemmed. The tape is used for tying up the patient's night- 
dress in order to keep it away from the vulva at the time of 
delivery and the white stockings take the place of the ob- 
stetrical leggings so many physicians use. The surgical 
supply houses in Boston put up two sterile obstetrical pack- 
ages. The first is the smaller and costs four dollars and 
the second costs six. This second larger package is the more 
satisfactory one for the patient to order and contains one 
bed pad 36 by 27 inches, lined with rubber sheeting. The 
rubber sheeting can be taken out after the delivery is over 
and used in the baby's crib, doing away with the necessity 



NORMAL PREGNANCY. lOl 

of buying extra rubber sheeting; four dozen small sterile 
pads; one swathe; six dozen sponges, three inches square; two 
papers of safety pins; several pieces of linen bobbin; two 
dressings for the cord ; four large pads, six by eighteen inches. 
These latter are used immediately after the delivery. There 
recently has been added one sterile gauze roller bandage 
three inches wide to be used for uterine packing. This pack- 
age sterilized comes sealed in a paper box and is left un- 
opened until the labor has begun. It should be in the house 
a month before the delivery is expected. If it is in the 
house longer than a month it is advisable to send it back 
and have it re-sterilized. This the supply houses do for a 
nominal sum when a package has been kept over a month. 



Preparations for Delivery. 

The choice of the room in which the patient is to be has 
usually been made many weeks before the onset of labor. 
The usual advice given in all text books that the lying-in 
room should have a sunny exposure, a fireplace and quiet 
is all excellent, but in these days of apartment life in the city 
many times it is out of the question. There is absolutely 
no choice. 

There is no need of stripping the room of its usual furni- 
ture. Unnecessary articles of furniture must be taken out 
and sufficient amount of room must be obtained to move 
about in comfortably. A single bed is desirable but in many 
cases a double bed is the one that is present. It must be 
so situated that both sides can be easily approached. If it 
is a low bed, it is most convenient for the delivery to have it 
raised up on blocks, eight inches high. These blocks at the 
present time, in Boston, can be hired for a nominal sum from 
the various surgical supply houses. They make it very much 
easier at the time of delivery, especially if it is an operative 
or a breech delivery. The nurse, after the delivery is over, 
appreciates a high bed more than anyone else. If the bed 
is a double bed and has a tendency to sag down in the middle, 
a leaf from the dining-room table can be put beneath the 
mattress to prevent this sagging. 



102 CASE HISTORIES IN OBSTETRICS. 

It IS important for the physician to know the arrange- 
ment of the bed for the dehvery. If it is an emergency case 
and the nurse has not arrived it is his duty to see that the 
bed is properly protected. Over the mattress should be 
placed a rubber sheet. If the rubber sheet is not large 
enough to go over the entire mattress then it must be so 
placed as to be underneath the patient at the time of de- 
livery. Over this rubber sheet comes the usual linen sheet 
and on top of this linen sheet is placed a sheet in which is 
encased one-half a rubber sheet. This last sheet is placed 
hanging over the right-hand edge of the bed at the point 
where the delivery is to take place. If it is long enough to 
go across the entire width of the bed well and good; if it is 
not it must be pinned so that it will cover the bed at the 
most advantageous point. This upper half sheet when the 
delivery is over is loosened and is then rolled away and in its 
stead is placed another draw-sheet. Whether you have a 
piece of rubber within this sheet or not depends upon whether 
an extra piece of rubber sheeting has been asked for. Usu- 
ally it is unnecessary, for a small bed-pad can be put directly 
beneath the patient. The bedclothes should be carefully 
drawn down and folded neatly at the foot of the bed. Care 
must be taken especially in the delivery that no unneces- 
sary soiling of bedclothes, blankets or the furniture takes 
place. The floor in the immediate vicinity of the bed must 
be suitably covered to prevent staining, and beneath the 
bed, where the delivery is to be, a basin or small foot- tub is 
placed to catch any excess of flow or any of the douche- 
water if a douche is used. 

Small tables are convenient to have for the instruments 
and the solutions but they are not essential and if they 
cannot be obtained chairs may be used. Physicians must 
be careful to cover whatever they use so well that no 
damage can be done. Usually, I place on the left-hand 
table my sterile goods and instruments and on the right- 
hand table the large basin or pail of sterile water or corro- 
sive sublimate 1-3000. I put my sterile goods and instru- 
ments at the left, that is, towards the head of the bed, so 
that the patient may not in an unguarded moment kick 



NORMAL PREGNANCY. IO3 

them over. This arrangement is for a normal deHvery with 
the patient on her left side, but in an operative delivery 
with the patient on her back it makes little or no difference 
on which side the instruments are placed, the physician be- 
ing guided simply by his own convenience. Within reach, 
the nurse has a small basin for the reception of the placenta 
and if this is not at hand it is not unreasonable to put the 
placenta after it has been inspected into the basin beneath 
the bed. The objection to this, of course, is that the nurse 
later has to pull it out from an unpleasant mess of blood 
and water. The use of a small basin does away with that. 

In the room, if the bathroom is not connected with it, 
should be a pail of hot water in order to resuscitate the 
baby. Further explanation of resuscitating the baby will be 
given in the section on the baby, page 478. The ergot, the 
hypodermic needle, and the necessary stimulants must be at 
hand. The sterile goods are placed on the table, but are not 
opened until just before there is need of them. I have 
spoken several times of sterile goods. I suppose the majority 
of patients are not delivered with sterile goods, but that is no 
reason why we should not have them. If the patient cannot 
afford to buy sterile goods from a surgical supply house or if 
there is no nurse on the case to put them up, there is no 
reason why the physician, if he is on the case even but a 
short time, should not boil half a dozen towels thoroughly 
and have them ready for use at the time of the delivery. 
They are not as comfortable for the patient as dry sterile 
towels, but they are much better than nothing. The prepara- 
tions for the delivery are many and in a multipara, where 
the labor may be very rapid, the nurse's ingenuity and brain 
are taxed severely and unless the physician knows what 
is essential, many times nothing will be right. 

Whether the patient should have a full tub bath depends 
upon her own cleanliness. Further than that it depends upon 
how active a labor she is in and how much dilated the os 
uteri is. It is a good routine rule that all patients at the 
very beginning of labor, unless the membranes are ruptured, 
should have a full tub bath. After the bath is given, the 
vulval hair must be shaved. I am confident that shaving is 



104 CASE HISTORIES IN OBSTETRICS. 

a necessity. I have never yet had any objection raised to it. 
Patients have been sometimes surprised that I should ask 
to have it done but they have never refused. If there is 
ever any objection it is a simple matter to explain to them 
that because of the amount of lochia that will be present 
after the delivery their comfort will be much increased, and 
this will be especially true if any stitches are necessary. I 
do not ask the nurse to take off all the pubic hair but I do 
insist that the lower vulval hair be shaved. Unless the 
nurse is expert in the use of the ordinary razor she had much 
better use the safety razor and thereby avoid all possibility 
of cutting the patient. Clipping I do not like for it often- 
times leaves many loose hairs about and if any operative 
procedure becomes necessary it is possible that hairs may be 
carried up into the uterus. After the vulva is shaved the 
patient is given an ordinary soapsuds enema in order to 
empty the lower bowel. The question of whether to give an 
enema to a patient when a doctor is not in the house is a 
real one, because it is a well-known fact that after enemata 
have been given, labors often start up very quickly. The 
nurse in Case 9 held off giving the enema until I was in 
the house for the reason that she was attending a multipara 
whom she did not want to start up in active labor until 
she knew that the physician was present, a perfectly justi- 
fiable procedure and one that is to be commended. 

The patient's hair should be braided in two braids and if 
this is not carefully attended to it becomes badly tangled 
during the delivery and causes the nurse much trouble later 
and the patient a great deal of discomfort. The patient usu- 
ally puts on an old night dress, one which may be torn if 
necessary and over this a wrapper is worn. At the begin- 
ning of labor there is no reason why she should not wear 
what she wishes. The question of allowing a nurse to make 
vaginal examination at this stage of labor I think allows of 
but one answer. No nurse in my opinion should be allowed 
to make a vaginal examination under any except the most 
extreme emergency. The only possible one I can think of 
is where she sees a prolapsed cord and pushes her fingers 
into the vagina in order to keep the head if possible away 



NORMAL PREGNANCY. IO5 

from the pulsating cord, but it is a question if that cannot 
be done better by putting the patient in the knee-chest 
position than by having the nurse attempt to hold back the 
head. Vaginal douches of any kind during labor I do not 
use. It has been conclusively shown that more harm than 
good may come from them. 

Unless there is some contra-indication the patients in the 
first stage of labor are allowed and urged to go about the 
room as much as they wish. The one chief contra-indica- 
tion is ruptured membranes with the liquor freely coming 
away. The highly neurotic girl of the present day will often 
refuse to walk about at all, and from the first pain she will 
lie in bed and complain, while in the lower classes it is with 
difficulty even in the second stage that one can persuade 
some of these patients to go to bed. Recent immigrants 
quite often will insist up to the last on being up or some 
may even assume a squatting posture. As labor progresses, 
if the physician has not already put in an appearance, the 
nurse must watch the interval of pains, their character, how 
the uterus acts and whether it relaxes well. She should 
know the rate of the fetal heart, the patient's temperature 
and her pulse. If there is any one of these points that is 
abnormal she must notify the physician at once. As soon as 
he comes he must make himself familiar with these points. 
I have come to feel recently very differently in regard to the 
question of food for a patient in labor than I did some years 
ago. With a patient in slight labor there is every reason 
why she should have food, but with a patient in active labor, 
whether it is the first or the second stage, I do not believe it 
best to give that patient much, if any, food for the simple 
reason that I have so many times found the process of di- 
gestion arrested when active labor is present. This has 
been shown many times when an operative delivery has been 
necessary, by the patient vomiting the food that has been 
taken into her stomach six to twelve hours before the ether 
was given. For this reason I hold that giving patients food 
if they are in active labor, or if there is the probability that 
they are going to have an operative delivery, is wrong. One 
may answer this statement by saying that the patient needs 



I06 CASE HISTORIES IN OBSTETRICS. 

food, in order to carry out her muscular exertion. I agree 
to this most assuredly, but if it is not digested and absorbed 
what possible good can it do? It simply nauseates her and 
causes her a great deal of discomfort. 

A patient in her first labor should be in bed when she be- 
comes fully dilated at the latest. A multipara should not 
be allowed to go to the toilet after she is half dilated unless 
she be in very desultory labor, but a patient in her first labor 
may go until she is fully dilated, provided, however, she has 
no inclination to bear down. Many patients towards the 
end of the first stage may have the desire to move the bowels 
and care must be exercised to prevent any untoward disaster. 

These preparations may seem to many practitioners al- 
most ludicrous. I have proved their value in my own expe- 
rience. Fortunately the time is fast passing when so low a 
standard for obstetrical work will be permitted as in the past. 
The physician who will not improve his standards will soon 
be without a practice. 

Technique of Delivery. 

Each physician will doubtless determine his own way of 
carrying on a delivery but there are certain fundamentals 
which must be thoroughly impressed upon the beginner. 
The first important point is the question of disinfection of 
the hands. The nails must be kept short and clean. Be- 
fore each vaginal examination the hands must be scrubbed 
thoroughly, with a boiled nail brush or one kept in corro- 
sive solution, for at least ten minutes. All parts of the hand 
must be scrubbed. Do not forget the interdigital spaces 
and the ulnar border. No rings are permitted on the hands. 
The hands are to be scrubbed in running water or in water 
that is changed at least two or three times. The soap is 
then washed off and the hands immersed in 70% alcohol for 
three minutes, carefully working the alcohol underneath the 
finger nails. Sterile gloves are then put on. For a vaginal 
examination there is no need of scrubbing up beyond the 
wrists, but for an operative delivery a thorough scrubbing 
must take place up to the elbows. In the preparation of the 



NORMAL PREGNANCY. IO7 

patient for examination I have already spoken of her being 
shaved. She is now placed in position for examination 
which is either the dorsal or the left lateral. I prefer the 
left lateral because there is less exposure and because it is 
easier for the patient to maintain. If the back position is 
used the patient is put well on the edge of the bed, legs 
flexed, with her feet resting on a chair. If it is the lateral 
position, and it usually is the left lateral, the buttocks are 
brought to the edge of the bed and the trunk of the body is 
at right angles to the length of the bed. Her legs are flexed 
on the abdomen and in that way the vulva points directly 
outwards to the side of the bed. The vulva is now scrubbed 
with soap and water. Before this scrubbing the hands 
of the nurse or the physician, if he is alone, must be care- 
fully washed. Care must be taken to scrub the vulva always 
downwards towards the anus and never from the anus towards 
the vulva. If the piece of cotton or gauze that is used touches 
the anal region it must be thrown away and not used 
a second time. Care must also be taken in patients who 
have a relaxed introitus not to use a great deal of water in 
washing and so let the dirty wash water run into the vagina. 
After the soap and water scrub, the vulva and adjoining 
parts are carefully washed off with corrosive solution 1-3000. 
It is unnecessary to scrub the patient's buttocks, and inner 
aspect of her thighs for under no circumstances should the 
examining fingers come in contact with thcvse parts. The 
wider the field that the physician thinks is prepared the less 
careful may he be. The patient prepared for examination, 
and your hand disinfection done, you proceed to make the 
vaginal examination. Every examination should be made 
with sterile rubber gloves without holes. The use of gloves 
is a protection to the physician as well as to the patient, for 
more than one physician has become infected with syphilis 
by vaginal examinations. 

If the patient is lying in the left lateral position, the ex- 
amination is made with the right hand. With the left hand 
the right labium is drawn upward so that the fingers of the 
right hand can be inserted directly into the vagina. Nothing 
is to be touched but the mucous membrane of the vagina. 



I08 CASE HISTORIES IN OBSTETRICS. 

This is important, for at best the vulva and vagina never are 
surgically clean. If the perineum is tight, insertion of the 
fingers a little way and then pressure backwards, towards 
the anus, on the perineum will gain room and then the 
fingers can be inserted further. At this time if it is the first 
vaginal examination that has been made of the patient, the 
relation of the baby to the pelvis must be at once determined 
as already noted. (Page 94.) If the pelvis has been settled 
as ample, at this time the height of the presenting part, the 
amount of dilatation of the os uteri and its physical charac- 
teristics, whether the membranes are ruptured or not are 
the points to be determined. If possible, the relation of the 
saggital suture and the posterior fontanelle to the pelvis 
should be settled. At the beginning of labor the question 
of a contracted pelvis ought not to have to be settled unless 
it is a border line case where the patient is to have the test 
of labor. This brings up an entirely different problem which 
will be dealt with later. For the normal case examination 
of the pelvis should have been done as already said at least 
three weeks before the expected date of confinement. If the 
physician has not done this then he may fairly be accused of 
having neglected his patient. Honest mistakes we shall 
make, but negligence must not be permitted. The question 
will be raised, is any vaginal examination during labor permis- 
sible? Examinations not carried out carefully undoubtedly 
are dangerous to the patient, but if the above precautions 
are scrupulously followed the danger of infection is so slight 
that it may be disregarded. The more often examinations are 
made and the further along in labor the patient is the greater 
is the risk. One examination, I practically always make, in 
a few cases two, almost never, unless there is some complica- 
tion, do I make three. 

At each and every time a vaginal examination is made 
this same method of procedure must be carried out. 

Make the first vaginal examination at the beginning of a 
pain. Be all scrubbed up and wait until the pain starts, 
then examine. By so doing, one readily tells whether the 
membranes bulge any and whether the presenting part de- 
scends. Another reason for making an examination during 



NORMAL PREGNANCY. IO9 

the pain is that the examination may be painful and often- 
times the patient does not distinguish between the labor 
pain and the pain of the examination, supposing the added 
pain is merely a stronger contraction. An objection to ex- 
amining at this time is that the novice may unintentionally 
rupture the membranes early in the labor, thereby making 
it a so-called ''dry labor." The object of a vaginal exam- 
ination in the first part of labor is to see that progress has 
taken place as shown by the dilatation of the os uteri. The 
advance the patient has made in the first few hours is the 
criterion of what we may expect her to do in the next hours 
provided she continues in the same type of labor. It has 
been said that the danger of making vaginal examinations 
is so great that they should be eliminated entirely and rectal 
examinations substituted. I have never had in my private 
work sepsis follow vaginal examinations carried out under 
this technique and for this reason I have never felt it neces- 
sary to give up vaginal examinations during labor and resort 
entirely to rectal examinations. 

The beginner will not know how to interpret what he feels 
in his first vaginal examination and unless he is under the 
careful supervision of his instructors, grave errors may come. 
A not uncommon mistake is for him to push the examining 
fingers by the os uteri into the posterior cul-de-sac and then 
to separate the fingers widely and say that the patient is 
fully dilated when in reality he knows nothing of the dilata- 
tion. Text books may teach the student what he may ex- 
pect to find, but experience in much practical work alone 
will make him proficient. 

In the large majority of cases the physician should palpate 
the fetus and listen to its fetal heart before the vaginal ex- 
amination is made. The same grips are used during the 
labor as were described in palpating in the preliminary exam- 
inations. By means of the fourth manoeuvre the progress 
of the head is followed. To appreciate this progress the 
mechanism of labor must be thoroughly mastered. Descent 
and flexion go on usually hand in hand. A specific case will 
explain this point. In Case 9 (page 55) palpation showed 
the position to be O. L. A. and the head well flexed. The 



no CASE HISTORIES IN OBSTETRICS. 

steps in determining these facts were these. Firm, smooth 
resistance was felt on the patient's left and the small parts 
found on the right. The head was known to be flexed be- 
cause by the fourth manoeuvre the fingers of the left hand 
met resistance further down in the pelvis on the child's occi- 
put than did the fingers of the right hand which were stopped 
relatively much higher up in the pelvis presumably by the 
chin. In other words, if a line were drawn from the tips of 
the fingers of the left hand to those of the right, the line 
would be upward and to the right. In right positions with 
the head well flexed the low point is on the right. When 
resistance is met on both sides at the same level then the 
supposition is that the head is slightly extended. If this ex- 
tension goes further the normal mechanism is altered and a 
brow or face presentation is found and the low point in the 
line is reversed (page 353). In some cases the abdominal 
wall is so tight that nothing can accurately be determined 
and then for accuracy recourse must be had to vaginal exam- 
inations. In palpating the abdomen during labor one must 
note whether the uterus is relaxing well between the pains 
and whether it is contracting hard or whether any tenderness 
is appearing. The length of pains and the interval between 
pains must be carefully noted. 

Careful inspection of the lower abdomen will show whether 
there is a full bladder present or not. This is shown by a 
round tumor mass in the midline rising up varying distances 
between the symphysis and the umbilicus. If this mass is 
percussed it is dull and on palpation it is resilient and at times 
tender. In Cases 41 and 42 it was readily seen. In both of 
these cases the patient was able to empty the bladder her- 
self. When this is impossible the patient must be cathe- 
terized. (For technique see page 124.) 

If the patient is in active labor but with the membranes 
unruptured the fetal heart need be listened to but once an 
hour, possibly once in two hours. When the membranes 
rupture, the fetal heart should be listened to at once. When 
the presenting part is not well engaged in the pelvis this 
is especially important. If it is regular and of the same 
rate as before the membranes ruptured, the probability is 



NORMAL PREGNANCY. Ill 

that the cord has not prolapsed. If it is not heard, or is 
irregular, a vaginal examination must be made to be sure the 
umbilical cord has not prolapsed. In the course of a labor 
with membranes ruptured the fetal heart must be listened to 
at least every forty-five minutes. If any irregularity or 
steady rise in the rate is found the question of operative in- 
terference at once arises. 

As the baby's condition is followed by its heart beat so is 
the mother's condition followed by her pulse. A steady 
rise in the maternal pulse is indicative of exhaustion. Ex- 
amination of the case histories will show operative deliv- 
eries undertaken because of a rising pulse. A slight rise in 
temperature is not infrequent and is not always a proof of 
beginning sepsis. The temperature of the patient must al- 
ways be taken at the beginning of labor for it may be of much 
diagnostic import in the puerperium. 

The question will often be asked how can the busy general 
practitioner stay with a patient who is in only fair labor 
and watch all the points above enumerated. Many times he 
will think he cannot afford from a pecuniary point of view to 
spend what he has allowed himself to regard as wasteful 
watching. Unquestionably in many cases it is unneccesary 
for the physician to be in the house all of the time the patient 
is in labor but he must be where he can be readily reached. 
If this is impossible then it is his duty to stay with the 
patient until her labor is over. In rural communities this 
is where the value of the trained district nurse becomes so 
great. 

One may write pages on the difference in the character of 
the first and second stages of labor pains. Practical work, 
however, will tell the beginner more than all that can be 
written. Here it is sufficient to say that the first stage pains 
are said to be nagging, bothersome, irritating, while in the 
second stage the pains, although harder, are better borne, 
oftentimes because of the feeling that the patient has that 
something is being accomplished. She oftentimes appreci- 
ates the progress that is being made and therefore accepts 
her condition more willingly. 

Each physician will develop his own way for carrying on 



112 CASE HISTORIES IN OBSTETRICS. 

the actual delivery. The following is one that has proved 
efficient many times. Reference to the cases will show the 
length of time for multiparous and primiparous labors. It 
is very variable and surprises because of the rapidity or the 
slowness of any given case are common. For this reason 
never allow yourself to say that a labor will be over within 
such and such a time. The liability of error is too great. 

In studying the above cases it is seen that all were delivered 
in the left lateral position. Unquestionably to my mind it is 
the best ; the one objection to it is that if you are alone with 
the patient it may be difficult for you to hold the patient in 
this position if she exercises little or no control over herself. 
But as the same objection holds in any other position in 
which the patient may be put this position still is the most 
satisfactory. The aseptic technique can be better carried 
out after the position is thoroughly understood than in any 
other way. There are two important points to be remem- 
bered, the patient's buttocks must be well on the edge of 
the bed with legs flexed, and the body must be at right angles 
to the length of the bed. 

The preparation of the room, the bed and the patient have 
all been noted above. 

As the second stage, the expulsion stage, begins, the patient 
is urged to bear down and use her abdominal muscles with 
each and every pain. Until the second stage begins, that is, 
until the completion of full dilatation, the patient must not 
be allowed to strain for if she does she simply tires herself 
out in trying to overcome the resistance of the undilated os 
uteri. Reference to the cases shows that if the membranes 
had not ruptured at or before full dilatation they now at 
full dilatation of the os were ruptured. With the gloved 
fingers it is difficult to rupture them and therefore a hemostat 
or a pair of rat- toothed forceps may be used. As the liquor 
comes away note whether it is the usual light color or stained 
with meconium. 

The physician should be ready for the delivery in a multi- 
para at the latest when she is two- thirds dilated. As a 
routine measure it is safer to be ready, at any rate for the 
beginner, from the time she is one-half dilated. For a pri- 



NORMAL PREGNANCY. 113 

mipara this is unnecessarily early, — here the first signs of 
bulging will give the physician sufficient time to scrub up, 
provided everything else is prepared. 

The bed pad is placed under the patient. The progress of 
the head carefully watched by the amount of bulging. Keep 
your hand away from the introitus. Nothing is gained by 
constantly putting the fingers between the perineum and 
the head thereby hoping to help stretch the perineum. More 
damage may come than any possible good; with each pain 
the patient is urged to bear down, holding her breath and 
using her abdominal muscles to the best advantage. 

By the time there is bulging of the perineum the sterile 
towels should be placed over the patient, one beneath her 
and one above on the upper buttock — placed lengthwise, 
the lower edge coming just above the upper labium. Have 
the third towel which is to cover the anus at hand but do 
not put it on, because one wishes to see the anus so that if 
any feces should be forced down by the oncoming head it can 
be wiped away at once. Again remember the caution above 
given, never to wipe toward the vulva, always toward the 
anus and then throw the piece of gauze away at once. 

In many books you will read descriptions of supporting 
the perineum to prevent lacerations. The term is a misnomer 
for the best way to prevent lacerations of the perineum is to 
keep from it all pressure from the outside. As the head 
comes in sight and the actual delivery is about to begin the 
physician sits directly in front of the vulva with the instru- 
ments and solutions on either side as already explained. 
With each pain the head will gradually advance. Pressure 
on the baby's scalp by the fingers of the right hand will indi- 
cate its condition. Pressure blanches the point pressed upon 
and as the fingers are removed the circulation is seen to re- 
turn provided the baby's condition is good. If there is no 
change when the pressure is removed the child's condition is 
grave and the delivery must be hurried (Case 13). With 
each advance of the head when the pain ceases there is a cor- 
responding recession. Gradually the perineum becomes so 
stretched that it is safe to hold the head at the point to which 
it has advanced, and this is done by placing over the anus 



114 CASE HISTORIES IN OBSTETRICS. 

the third towel one end of which lies on the upper buttock, 
over the first mentioned towel. Then press the fingers of 
the left hand in behind the anus to catch the oncoming 
chin. By the presence of this towel the left hand is not 
soiled. If the advance becomes too rapid, and it not infre- 
quently does, the head is held back by the right hand. The 
tips of the four fingers and the thumb are placed together on 
the fetal head and firm pressure made against it. The 
amount of resistance given to the head is governed by the 
speed with which it is safe to let the brow and face come 
over the perineum. Experience alone can tell you. The 
more experience you have the slower will be this stage in the 
delivery. If you are unable to keep back the head by the 
pressure of the fingers let the elbow point of this arm (the 
right) drop down to the inner side of the right thigh, just 
above the knee, and by this manoeuvre you gain the added 
strength of the adductor muscles of the right leg which is 
not inconsiderable. 

With the head as far advanced as it now is the patient 
should have had everything which she may have been pulling 
on taken away and she should begin to breathe quickly with 
the mouth wide open, — to pant. By this means her abdomi- 
nal muscles are stopped working and the uterus alone expels 
the baby. With the left hand behind the anus holding the 
chin and the right hand stopping all advance you have the 
head within your control to deliver it when you are pre- 
pared. The head should always be delivered in the interval 
between the pains, never as the pain is coming on for the 
liability to a severe laceration of the perineum is thus greatly 
increased. The occiput must be kept close to the symphysis 
and as much pressure as possible kept from the perineum. 
Gradually, the brow, eyes, nose, mouth and chin appear in 
turn and as the chin is born the whole head drops backward 
towards the anus and as it does this, with the left hand the 
edge of the third towel is slipped beneath it to prevent it 
touching the anus. If the perineum is tight, room may be 
gained by rotating the head a few degrees the way it is going 
to restitute so that the nose and chin are delivered a little 
off the middle line. 



NORMAL PREGNANCY. II5 

The moment the head is born it turns either towards the 
right or left of the patient's pelvis depending upon the posi- 
tion in which the fetus was. This first turning is called 
restitution, in other words, the head at once turns so that it 
comes to be in its accustomed relation to the shoulders, the 
saggital suture of the head lying at right angles to the bis- 
acromial diameter of the shoulders. 

The head delivered, the mouth at once is quickly, but 
gently wiped out. The cord is felt for about the neck and 
then the eyes wiped off with sterile gauze or with sterile 
gauze moistened in boric acid solution, 4%. Be in no hurry 
to deliver the shoulders unless the baby is in poor condition. 
If the cord is about the neck try first to pull it down and slip 
it over the head, if this is impossible, as the shoulders are 
born slip it over the one or the other. Occasionally neither 
of these procedures can be done and then you must put on 
quickly two hemostats and cut the cord between them. 
(Case 9.) One hemostat is not sufficient, for you cannot tell 
whether you will cut on the fetal or on the maternal side of 
where the one snap was placed. 

If the head is watched carefully after restitution takes 
place, it is seen to turn still more in the same direction with 
the next pain. This further turning is called external rota- 
tion, or a better name for it is internal rotation of the shoul- 
ders. By this mechanism the anterior shoulder comes to 
the arch of the symphysis and then is born. I frankly can- 
not say which shoulder should be delivered first; generally 
it is the anterior, sometimes the posterior, and it makes no 
essential difference. It is certain, however, that both should 
not come at the same time for an unnecessary amount of 
pressure is put on the perineum. Let whichever one comes 
the more easily come down. If any traction is necessary 
let it be slow and deliberate, never a quick sudden motion. 
If the anterior shoulder comes first then draw it upwards 
towards the symphysis thereby taking as much pressure as 
is possible off the perineum. Many little points will be 
apparent to the careful physician which he can make use 
of as he becomes thoroughly familiar with the numerous 
problems with which he must deal. As the shoulders are 



Il6 CASE HISTORIES IN OBSTETRICS. 

born, the body follows and bends laterally, — lateral flexion, 
— away from the physician, again keeping as much pressure 
as possible from the perineum. The right hand supports 
the head and shoulders, and as the body follows the left slips 
down along the buttocks and the ankles are caught. Grasp- 
ing both legs at the malleoli, the middle finger of the left hand 
between the two ankles, the index and ring fingers around the 
two external malleoli, the baby is held up by the feet 
and drained. The head is grasped and extended in order 
to straighten the trachea. Sometimes the head may be 
gently shaken to clear the mucus. The little finger is then 
passed into the mouth and hooked about in order to get 
out any mucus which may be resting in the mouth. While 
the baby is draining feel the cord for pulsations. At this 
time the baby practically always cries; if it does not the 
problem of resuscitation arises and this will be taken up 
later (page 478). 

Provided the mother and baby both are in good condition 
wait until the cord stops pulsating before you tie it. The 
blood in the cord and placenta belongs to the baby and series 
of cases have shown that babies who obtain this blood do 
better than the ones who do not. If either is in poor 
condition snap the cord with a hemostat and cut at once. 
Wait until conditions are such that you may put the ties on 
the cord. The method of tying the cord is important and 
I know of none better than the usual one, provided it is 
carried out carefully. The bobbin which must be sterile 
is placed half an inch from the umbilicus and half a square 
knot made. The ends are held in the hands, across the palms, 
between the thumbs and index fingers, the thumbs then are 
brought together and with an outward rotation of the wrists 
the first half of the knot is sunk home and then the second half 
is tied in the same manner. The reason for this is that if 
one hand slips the other does not pull away with the other 
end of the bobbin and tear the cord from the abdomen. 
Unless this precaution is taken this accident may take place 
as I have seen it. Always place a second tie in a similar 
manner half an inch beyond the first and then the cord is 
cut just beyond this second tie. After it is cut sponge with 



NORMAL PREGNANCY. II7 

sterile gauze the cut end and watch it for a few moments 
to see that there is no bleeding. The baby, in a sterile towel, 
is then put in a safe and warm place to be attended to later. 

The nurse's position at the delivery is sitting on the bed 
facing the patient, just in front of her. In this position the 
nurse can readily follow down the uterus, as the baby is 
born, with her right hand and can also watch the mother's 
pulse. Just before the head is delivered the nurse places 
her right hand on the fundus and keeps it there during the 
remainder of the delivery. She uses no force unless re- 
quested to. The reason for her following down the uterus 
in this way is that she then has the fundus in her grip at the 
beginning of the third stage. If she holds the uterus well 
from the time the baby is born until the placenta comes 
away there is little or no danger of an internal concealed 
hemorrhage taking place. She takes notice of the size of 
the uterus the moment the baby is born, and if she is keen 
she will notice and report any enlargement. 

If you are alone with the patient grasp the fundus yourself 
and then put the patient's hand on it and tell her to keep 
her hand where you put it. If she will not or cannot, at fre- 
quent intervals feel of the fundus yourself and make sure it 
is remaining hard. Remember if you do have to grasp the 
fundus you must prepare your hands again for the delivery 
of the placenta. At this time take the patient's pulse; 
accurate observation of it at this time may save much worry 
later. 

The baby born, the third stage begins. The patient now 
slowly rolls over on her back from the left to the right, her 
legs steadied by the nurse or some friend, or resting on a chair. 
If there is no bleeding and the patient's condition is good 
there is no indication to hurry the delivery of the placenta. 
The reason for changing to the dorsal position at this time is 
that a more careful inspection of the perineum may be given 
with the patient in this position. Also there is less soiling 
of the bed and the uterus can be held to much better ad- 
vantage. A good routine rule in the delivery of the placenta 
is to wait for six contractions, or a half hour, before any at- 
tempt is made to express it, provided of course that there is 



Il8 CASE HISTORIES IN OBSTETRICS. 

no absolute indication to deliver it. When the placenta is 
delivered it must be inspected to see that it is intact and 
that all the membranes are present. This is done by holding 
the placenta in the palms of the hands maternal surface up- 
wards. By approximating the various cotyledons one at 
once sees whether they make a complete placenta. The 
membranes are then stretched out and if they form a bag 
with only a small rent you may be reasonably sure they are 
all present. 

In the majority of cases the fetal surface of the placenta 
appears first at the vulva. It is grasped first by one or both 
hands and gently drawn out of the vagina. Do not let it 
come quickly for the membranes may tear with the result 
that some may be left in the uterus. The placenta is rotated 
to the left or to the right in order to twist the membranes 
into a cord and they then are gradually drawn out. If the 
membranes hold, put a snap on them at the introitus and 
continue to twist them and at the same time pull them gently 
out. If but little comes place another snap higher up on 
the membranes and continue twisting and pulling very gently. 
Gradually more and more of the membranes come down and 
finally the end comes trailing out. Occasionally if the uterus 
is held down too tightly by the nurse one will tear the mem- 
branes if one is not careful; in such cases ask the nurse to 
let go of the uterus entirely for a moment or ask the patient 
to cough. Slight traction at the same time on the twisted 
membranes will usually bring them away complete. 

If you find that all the membranes have not been obtained 
and some parts remain in the uterus do not go up after them 
at once unless there is hemorrhage. In by far the large 
majority of cases they will be discharged in the lochia and 
no symptoms arise. (Case 12.) If there is hemorrhage the 
uterus must be cleaned out, either by a finger curettage, or 
the curette, or the cavity of the uterus wiped out with sterile 
gauze. Rarely the uterine cavity will have to be packed. 
The third stage ends with the delivery of the placenta and 
the puerperium then begins. 

The perineum must be carefully inspected. The labia are 
separated and the vagina carefully and gently sponged. If 



NORMAL PREGNANCY. II9 

a slight tear is found the stitches may be placed while you 
are waiting for the placenta, and after it comes away they 
are tied. The majority of tears are sewn up without ether 
if they are sewn at all. Every tear no matter how slight, 
should be repaired, using chromicized catgut for internal 
tears and silk worm gut for external tears. Never act as a 
physician recently told me that he did. He said he could not 
afford to put in "stitches" as the older men in the com- 
munity where he practised never sewed up any of their cases 
and should he get the reputation of putting in ''stitches" he 
would get no work! If the tear is a bad one the patient 
should be etherized and a careful repair done. In the various 
cases the technique of repairing the perineum is described. 

After the placenta is delivered the patient is cleaned up. 
One must be careful as in the scrubbing up never to wipe 
towards the vulva. A douche must not be given. The 
patient is now rolled back into bed and made comfortable. 
She must keep as nearly fiat as is possible with legs extended. 
If there is a nurse with you it is her duty to follow carefully 
the pulse and if there is a rise in rate she must tell you at 
once. If you are alone take it the moment the patient is 
put back in bed. The nurse also should hold the uterus. 
She has followed down the uterus as the baby is delivered 
and has kept her hand on it during the third stage. The 
only time that it is not held is when the patient is being 
rolled over from the left side to the back position for the de- 
livery of the placenta and inspection of the perineum. The 
nurse at this time changes her position and comes and sits 
on the patient's left so she can again grasp the uterus with 
her right hand. If the uterus is not acting well and by 
acting well one means staying well contracted, the physician 
grasps the fundus as the patient's position is changed. Again 
let me repeat that he must wash up his hands again before 
the delivery of the placenta or else change his gloves. This 
is the reason for having two pairs of gloves sterilized for every 
delivery in order to have a clean pair for the delivery of the 
placenta and the repair, if necessary, of the perineum. In 
holding the uterus the four fingers should be behind the 
uterus, the palm over the fundus and the thumb anterior, 



120 CASE HISTORIES IN OBSTETRICS. 

pointing to the symphysis. There is no necessity of hurting 
patients in holding the uterus; no sudden motions must be 
used. If the uterus does not contract well gentle manipula- 
tion of the fundus between the fingers and thumb will many 
times bring good contractions. Management of the uterus 
which does not act well will be taken up under post-partum 
hemorrhage (pages 76 and 233) . The use of ergot as a routine 
measure after the placenta has been delivered is unnecessary. 
Ergot must never be given until the placenta is delivered 
because of the danger of shutting down the uterus on the 
placenta, making its delivery most difficult and sometimes 
dangerous. (See Case 37A, where ergot was given before the 
placenta was delivered.) If the physician for any legitimate 
reason cannot stay with the patient for two hours after the 
completion of the third stage and there is no competent nurse 
in charge, a dram of ergot may be given as a precautionary 
measure. Care must be used to obtain an active preparation 
of ergot for it is well known that ergot deteriorates with age. 

The uterus is held until it stays well contracted. This may 
mean not at all or for some hours. In a certain few cases, 
especially in multiparae the uterus will act poorly and careful 
attention must be given it or a severe post-partum hem- 
orrhage may result. Immediately after the delivery is com- 
pleted and the patient is back in bed there are three points 
which must be carefully determined. First, the pulse, sec- 
ond, the action of the uterus, third, the amount of flowing 
that is present. The pulse should drop in rate immediately 
after the delivery and unless you have followed it carefully 
through the delivery you will not know whether it is drop- 
ping or rising. A rising pulse rate is a danger signal and its 
cause must at once be found out. The action of the uterus 
has already been spoken of. The flowing varies consider- 
ably in amount but if the pulse drops in rate or remains of 
the same rate and volume no anxiety need be felt. 

With a dropping pulse rate and a good uterus the abdom- 
inal binder may be put on at once. But with reversed con- 
ditions it is never to be put on. The binder should reach 
from just above the trochanters to just below the ribs. A 
firm smooth binder adds much to the patient's comfort. It 



NORMAL PREGNANCY. 121 

relieves the sense of emptiness that so many patients speak 
of at once after delivery. It cannot in the first few days of 
the puerperium cause a retroversion. Before the binder is 
put on let the patient try to void her urine. If she is success- 
ful before the bladder has had time to become distended the 
probability is that she will have no difficulty later. The 
vulva pad is pinned to the back of the binder over the sacrum 
and to the front over the symphysis. After the patient's 
swathe is applied the patient's temperature and pulse should 
be taken. She then should be given before she quiets down 
for sleep a cup of broth, hot milk or cocoa. She has done a 
great deal of work and she needs not only food but sleep. 
The question of an early sleep is important because of the 
hard work and oftentimes the loss of sleep. The room that 
the patient is in must be darkened and the whole household 
must be kept quiet. When the patient has been made com- 
fortable the nurse then turns her attention to the baby. (See 
page 477.) 

The Puerperium. 

The temperature and pulse of every puerperal case, pro- 
vided a nurse is on the case, should be taken every four hours 
until the milk is well established and from then on twice a 
day until the patient is up. If you have no nurse to look 
after your patient make it a point to make the visit on the 
second and third days in the mid-afternoon, because if the 
patient is to have any temperature she will much more likely 
have it in the afternoon than in the morning. If one's work 
is so arranged that it is impossible to see the patient in the 
afternoon one can always leave a thermometer in the house 
and let her take her own temperature and in that way one can 
early discover any rise in temperature. An initial rise of 
temperature immediately after a delivery is so common that 
one thinks nothing of it. A temperature of 102° within six 
hours after delivery is not unusual and a temperature of 100° 
is very common. It has no significance and without doubt 
it will drop to normal within twelve hours. The tempera- 
ture must be kept accurately. There ought never to be a 
continued temperature of over 100° in a puerperal patient. 



122 CASE HISTORIES IN OBSTETRICS. 

The British Medical Association records cases as showing a 
puerperal morbidity in which the temperature exceeds 
100° F., in two successive bi-daily readings from the end of 
the first day to the eighth day after delivery. 

The pulse rate to me is far more important than the tem- 
perature. Immediately after the delivery in all cases there 
should be an initial drop in the pulse rate. It may come 
down to 45-50 and then gradually as the heart becomes rested 
rise to its usual rate. A rising pulse in the puerperium one 
can always regard as a danger signal. The rising pulse often- 
times shows the presence of trouble sooner than anything 
else. By an accurate pulse chart one can tell a great deal 
better about the patient's condition than by any other one 
sign. 

Shortly after the delivery a post-partum chill may occur. 
It is very common and has no significance. It may be of 
nervous origin or due to the alteration in the circulation or 
to the loss of heat of the baby. The treatment indicated is 
simply to put heaters and more blankets about the patient 
and to assure her that the chill will cease very shortly and 
is nothing to be alarmed about. It may be so severe that 
morphia may have to be given. (Page 174.) 

The question of food in the puerperium is an important 
one. Immediately after the delivery, as I have already 
said, liquids of some sort must be given because of the hard 
work the patient has done. For the first twenty-four hours 
soft solids, toast, milk, dropped egg, cereals, etc., may be 
given. After the bowels move there is no reason why, unless 
there is some positive contra-indication, the patient should 
not go on to the regular diet that the family is having, but 
while she is in bed it must be remembered that she does not 
need such a full diet as if she were up and around doing her 
routine work. One thing must be remembered, do not let 
the nurse or the friends of the patient begin to cut her off 
from one thing after another because they are afraid this or 
that will upset the baby. The patient can eat anything that 
she wants except the things which she, herself, knows upset 
her when she is up and around. A good generous mixed diet 
is the best for making milk. Her bowels must move by the 



NORMAL PREGNANCY. 123 

third day unless she has a severe tear and you plan to stop the 
bowels from moving for some days. As is seen in the above 
cases, I practically always use castor oil, three-quarters of 
an ounce to one ounce. There is no cathartic that clears the 
intestinal tract so well for the first movement as castor oil. 
It must not be continued. One dose only is given. From 
then on the patient must have one movement a day. Whether 
she gets it by the use of enemata or by a mild cathartic is im- 
material but I am firmly convinced that if the patient is re- 
lying on enemata alone she should have at least twice a week 
a mild cathartic by mouth. Some patients find that the 
use of suppositories is entirely satisfactory and the same 
remark holds true about the use of mild cathartics, if they 
are relying upon suppositories alone as upon enemata. 

It is not unusual to find that a patient just delivered is 
unable to pass her urine. The abdomen, relieved of the 
pressure of the fetus, is very relaxed and as the bladder en- 
larges there is no sensation of fulness and the nurse soon 
finds that the patient has a full bladder. When the patient 
attempts to void she is unable to do so. The patient should 
early attempt to pass her urine and should not be allowed to 
go a long time without so doing. If a patient cannot void, 
sometimes, rarely in my experience, the sound of running 
water has helped her. Occasionally a hot sterile cloth ap- 
plied to the vulva or hot sterile water poured over the vulva 
will be of aid. A hot sterile douche with a fine stream pointed 
directly at the meatus with the labia separated, the stream 
coming with some force, may help. I have had greater success 
in having a very large high hot enema given to the patient. 
When the enema comes away in almost every instance it 
will be found that the patient has passed her urine at the 
same time. The enema cannot be used if there have been 
severe lacerations. If none of these procedures proves of 
value, raise the patient up in bed supporting her in an up- 
right position. (Case 41.) Patients then can usually pass 
their water. If all of these measures fail she must be cathe- 
terized. Catheterization is the last resort and should never 
be done until all these other measures have failed. Cathe- 
terizing a puerperal patient is a dangerous procedure. I 



124 CASE HISTORIES IN OBSTETRICS. 

care not who it is that does it, it is oftentimes the beginning 
of a long cystitis. If the patient is to be catheterized, the 
catheterization is a surgical procedure and unless you are 
sure of your nurse you must do it yourself. Accept the 
responsibility yourself if there is an infection and do not put 
it on the nurse. The patient should be on her back with the 
legs flexed and the knees dropped outwards. You must see 
the meatus. Fortunately, the time has gone by when the 
patients are catheterized under the bedclothes. The vulva is 
carefully wiped off with corrosive sublimate 1-3000 and a 
pleget of sterile cotton soaked in 4% boracic acid solution is 
placed over the meatus. The nurse's hands are made surgi- 
cally clean. The labia are separated with the fingers of the 
left hand and the meatus is in full view. With the right hand 
the catheter is gently inserted into the meatus without 
force, with a gentle sliding motion. If the catheter is in- 
serted in the meatus there is no difficulty. It must not touch 
any point except the meatus. Whatever kind of a catheter 
is used, it must be thoroughly boiled just before use. I 
prefer in the puerperium a glass or a metal catheter. If the 
urine comes do not move the catheter. Let well enough 
alone. In removing the catheter the finger is put over the 
external end and the catheter then withdrawn. The un- 
fortunate part about catheterization of a patient is that if 
it is once begun, in the majority of cases it has to be kept up. 
A patient lying in bed should have a bath every day. How 
often the pads are changed depends entirely upon the amount 
and character of the lochia. The pads should be changed, 
however, at least four times a day. Of the various antisep- 
tics that are used, corrosive sublimate, lysol, sulpho-napthol, 
the physician must determine himself. Personally, I do not 
care to have any used. Sterile water is sufficient. When 
the nurse is ready to clean the patient she washes her hands 
carefully, and whether she uses gloves or not depends en- 
tirely upon whether the patient has syphilis or gonorrhea. 
The nurse should always clean the vulva from above down- 
wards and never in the opposite direction. Many nurses 
pour sterile water over the vulva. The advantage of this is 
that if the patient has not been shaved it causes her less pain. 



NORMAL PREGNANCY. 125 

The disadvantage of it is, that if the introitus is relaxed some 
of the wash water will go into the vagina. After the vulva is 
clean a sterile pad is put over the patient. Whether the 
patient is of the class that can afford to have sterilized pads 
or whether she simply makes up her own pads in the house- 
hold and bakes them well in the oven or uses absorbent cotton 
soaked in corrosive sublimate 1-5000 makes no difference. 
She must have something over the vulva to absorb the dis- 
charges. If there is not a nurse on the case it is the duty 
of the physician to show the attendant how the pads may 
be put on without touching the surface which is to be against 
the vulva. In the out-patient service at the Boston Lying- 
in Hospital we use absorbent cotton soaked in corrosive 
sublimate 1-5000. The pads are so folded that the inner sur- 
face can be put at once on the patient without the ignorant 
attendants handling them. If the patient is torn badly 
there is no question but that a dry sterile pad is the most 
comfortable, and that we obtain the best results from them, 
rather than from a moist pad. If the pads are not covered 
with cheese cloth or gauze, a binder is necessary to hold 
them in place. 

The use of post-partum douches is absolutely contra-in- 
dicated. It has been shown again and again that they are 
of no service and that infection has followed their use. Un- 
questionably there is a certain legitimate field for the use 
of vaginal douches (Case 73) , but in routine cases the employ- 
ment of a vaginal or intra-uterine douche is absolutely con- 
tra-indicated and a relic of past ages. 

The care of the breasts is an important part of the puer- 
perium. I have already spoken of the care of the breasts 
during pregnancy (page 88). When the patient has had 
her first rest after the delivery, the breasts should be washed 
off with soap and water and then a simple ointment put on 
the nipples on small sterile squares of soft linen. No attempt 
must be made if there is dry secretion on the nipples to take it 
off until it is softened by an ointment. I have used with 
satisfaction a 4% borated lanoline ointment for the nipples. 
How soon one determines to put the baby to the breast after 
the delivery depends much upon whether there is any milk 



126 CASE HISTORIES IN OBSTETRICS. 

or not in the breasts. The tugging away at the nipple by 
the baby when there is no milk present is without doubt a 
potent cause for making the nipples sore. The baby gets 
nothing, bites the nipples and in a very short time cracks 
appear. If any secretion is present, there is no reason why 
the baby should not be put on eight or ten hours after it is 
born. There is no question, if it can be done, that it stimu- 
lates the breast tissue to secrete, but it is a doubtful procedure 
if there is no milk present. Before the milk comes in, while 
there is only colostrum in the breasts, once in four hours 
will be sufficient usually to satisfy the baby; as the engorge- 
ment increases the baby may be put to the breast every two 
hours and be allowed to nurse the breasts out well. There 
is no harm occasionally in letting the baby stay on so long 
that it may get too much and then regurgitate some of the 
milk. The relief that it gives the mother is usually worth 
the once or twice that the baby may regurgitate. If the 
breasts are full and pendulous there is no binder that is quite 
so satisfactory as what is known as the Boston Lying-in 
binder, sometimes called the Y binder. Two towels and 
safety pins are needed. The towels are folded lengthwise 
into strips about four inches wide, — the exact width is de- 
termined by the size of the breasts it is to be applied to. One 
arm of the Y goes above the nipples on the breast tissue and 
the other arm goes below. The binder is held in place by 
shoulder straps above and attached to the abdominal binder 
below. In order to have the binder smooth and give even 
support, absorbent cotton is placed where needed about the 
breasts. This binder should be put on for support and not 
for pressure. The relief that it gives the patient is astonish- 
ing and a physician himself should know how to put it on. 
Put on well, it is of great service, but put on badly it is worse 
than none at all. 

Each time before the baby nurses the so-called breast 
tray should be brought to the side of the bed. The breast 
tray consists of the bottle of 4% boric acid solution, a bottle 
of 70% alcohol and a jar of 4% borated lanoline, sterile 
absorbent cotton and sterile linen squares. The patient 
is placed in the correct position for nursing and the 



NORMAL PREGNANCY. 127 

nurse's hands are washed. She then takes a little absorbent 
cotton, moistens it with boric acid and wipes off the lanoline 
which is already on the nipple. The baby is then put to 
the breast and after the nursing is over the nipple is again 
wiped off with the absorbent cotton wet with boric acid. 
If you believe in the use of alcohol the nipple is wiped off 
with the alcohol and after that the borated lanoline is put on 
the nipple. Usually these measures are very satisfactory 
and the nipples become hardened very quickly and cause no 
trouble. If the nipples become tender or painful to the 
nursing, the use of the nipple shield is at once indicated. 
With increasing tenderness, apply at once compound tinc- 
ture of benzoin to the nipples. This is put on with a camel's 
hair brush in three layers, allowing each layer to dry before 
the succeeding layer is put on. In many cases this simple 
procedure will be all that is necessary to overcome the ten- 
derness of the nipples. Occasionally the use of alcohol and 
compound tincture of benzoin hardens the nipple so much 
that the skin may crack more readily than if they were not 
used. If you use the nipple shield it must be boiled each 
time before it is used. A little boiled warm water is put in 
the shield and it is then put on the nipple. Care must be 
taken not to have the nipple shield and water so hot that the 
nipple will be burned. If this does not prove sufficient to 
heal the cracked nipple the baby must be taken off the breast 
for one or two nursings in order to rest that nipple. 

The number of visits that you will find it necessary to 
make depends entirely upon how the patient progresses and 
upon the ability of the nurse that you have on the case. If 
there is no nurse, the patient must be seen within twelve 
hours after delivery. The following important facts must 
be noted : the temperature and the pulse, the size and consist- 
ency of the uterus, the amount of lochia and its character, 
whether the patient has voided or not, whether she has 
slept and if she has taken nourishment. The points to be 
noted in regard to the baby are taken up in the section on 
the baby. Never visit a patient unless you determine all 
the above points, they take but a few moments and if you 
do not know them at the beginning of the puerperium you 



128 CASE HISTORIES IN OBSTETRICS. 

may become much troubled later. The patient should be 
seen again on the second and third days. If all is normal at 
these visits the fourth day may be skipped. Gradually the 
intervals are lengthened as the case progresses. Every case 
before it is discharged should have a pelvic examination. 
It is important for the patient's future health to know that 
the pelvic organs have returned to their normal condition. 
If the uterus is found to be large or retro verted, proper 
treatment at this time will usually speedily correct these 
conditions and insure health to the patient later, while if 
they are neglected, much discomfort may follow. The im- 
portance of this examination is seen by reference to Case 12. 

In all cases the temperature and pulse must be recorded; 
do not rely upon your memory from day to day. A glance 
at the chart will show at once whether the patient is doing 
well or not. A chart only partially filled out is of more 
service than one's memory. The uterus should involute 
steadily; the individual rate, however, varies within very 
wide limits. It should not be tender to palpation unless for 
evident reasons, such as holding it after delivery for some 
hours and in such a case it should become less and less 
tender. 

For the first few hours, six is a good routine, the patient 
must stay absolutely flat on her back, head low, and avoid 
all muscular exertion. She then may be rolled over on one 
side or the other. After the first twenty-four hours she may 
turn as she wishes in bed. The reason she is told to keep 
so quiet is the fear of an embolus. But when one realizes 
how quickly the women of the poor get up and about it 
makes one wonder how much exertion alone has to do with 
the causing of an embolus. My private patients are kept 
in bed fifteen to twenty-one days. The last week they sit 
up in bed for their meals and then lie down with one or two 
pillows as they elect. Whether the German idea of getting 
patients out of bed in three to five days will prove advan- 
tageous or not remains to be seen. I have never tried it 
but I doubt if our high-strung neurotic girl of to-day will 
stand such treatment. I now have a patient under my 
care who eighteen months ago was routed out of bed on the 



NORMAL PREGNANCY. 1 29 

third day after delivery in Germany. She has no desire to 
repeat the experiment within the next few weeks. 

From the fifth to the tenth day of the puerperium, I have 
all my patients begin active leg exercises. First dorsal 
and plantar flexion, circumduction, of the foot, flexion of 
the knees. If there has been no laceration of the perineum 
I add the following exercise. The knees are flexed and then 
dropped outwards, the nurse then gives resistance to adduc- 
tion by pressure on the knees. These exercises are at first 
done for five minutes once a day, then for five minutes twice 
a day and gradually increased to fifteen minutes twice a day. 
Rarely do these first simple exercises increase the lochia. If 
it does, and it becomes bright red, stop the exercises for 
forty-eight hours and then begin again. By the twelfth day 
raising first one leg and then the other to right angles 
with the body is begun. The next day the attempt is made 
to raise both together. If the patient cannot do this and at 
first it is quite common that she cannot, the nurse raises 
the legs slowly for her. The patient then lets the legs come 
down slowly to the bed. Slowness is essential for the best 
results in all of these exercises. There are few patients who 
do not feel the muscular exertion these entail. They must 
not be done to the point of fatigue. Gauge your patient and 
know what her muscular development is and tell her defi- 
nitely how many times she may attempt to raise her legs. 
Such exercises as these will many times entirely do away 
with the prickling of the feet that is so annoying when the 
patients get up. Again and again have I had patients get 
out of bed on the fifteenth to eighteenth day after delivery 
and walk with a steady step. If the abdominal wall is much 
relaxed, after they are out of bed I advise them to keep up 
these last mentioned exercises and add the raising of the 
head and shoulders and body to right angles to the legs from 
a horizontal position on the floor. 

If the patient conscientiously carries out these exercises 
she will recover her figure, which she so much desires, more 
quickly than in any other way. Usually a patient's one idea 
in getting up is to put on her corsets. If they are properly 
fitted ones, ones that do not press the abdominal contents 



130 CASE HISTORIES IN OBSTETRICS. 

downwards, there is no reason why she should not wear them 
at once. Exercises will do more, however, for her figure 
than any corset. Corsets are an easy but vicious way of 
accomplishing what she desires. Patients must be warned 
if they are nursing not to wear high corsets that may impinge 
on the breast tissue for if they do, damage may be done. 

Massage of the legs may be begun the first twenty-four 
hours and is most useful to keep the muscles in good condi- 
tion. Gentle rubbing of the legs shortly after the delivery 
is many times most soothing to the patient and can cause no 
harm. 

If the patient has been badly lacerated at the delivery or 
shows any sign of sepsis these exercises are contra-indicated 
because of the added danger of embolus. In a normal case, 
however, this added danger is not present and the exercises 
cannot be regarded as a possible cause of an embolus. 

Such is the routine which has proved satisfactory in my 
hands. The fundamentals remain the same. Each case 
varies in its management and one is ever ready to change 
the routine to suit the individual conditions. 

Reference to the cases show^s that all of the normal cases 
but one were delivered with ether. The patients had no 
knowledge of when the baby was born. I recently found an 
old book on obstetrics, published in 1848 written by Hallich 
which contains the following passage: 

''There are some persons, I know, who say that this suffer- 
ing has been ordained for woman and that it ought to he en- 
dured. This notion, I think needs no refutation, it being 
just as unreasonable as to say that the sick should be allowed 
to suffer and die without assistance because their condition 
has been ordained. There are others, and men of science, 
too, who think that the pains of childbirth are necessary to 
its safe accomplishment, and that they are also valuable in a 
moral point of view." 

There is no reason why ether should not be given in every 
normal labor. If you use it there are certain definite rules 
to follow. If the labor is slow and inefficient with irregular 
pains both in time and strength of contractions ether may 
stop all contractions and greatly delay the delivery. Before 



NORMAL PREGNANCY. 13 1 

ether is started the patient must be well along towards the 
end of the first stage. The pains must be coming regularly 
and of good strength. Ether must be given only with the 
contraction, as felt by the physician or nurse, not as asked 
for by the patient, and as soon as the contraction is felt 
to pass the ether is taken away. In this way the patient 
may be carried along some hours if necessary. At no time 
does she completely lose consciousness. In a few cases the 
patients become excited and lose control of themselves when 
ether is given, and in these patients one sometimes is dis- 
appointed in its action. Many patients will work much 
better when ether is given them. Gradually as the perineum 
becomes distended and the baby is about to be born the ether 
is forced and as the delivery is accomplished full surgical 
anesthesia for the moment is obtained. Ether then is 
taken away from the patient and she quickly becomes con- 
scious. Carefully given it causes no complication. I prefer 
it to chloroform for it is much less dangerous. 

In the past year and a half I have given nitrous oxide and 
oxygen anaesthesia a very thorough trying out and I am 
convinced that it is absolutely safe to both mother and child. 
A small dose of morphia or in some cases chloral hydrate 
in the early stage of a normal labor and the use of gas-oxy- 
gen later give a very satisfactory analgesic which in no way 
endangers either mother or child. The apparatus I have 
used is the Flagg. It is small, readily carried about and on 
the whole satisfactory though there are some slight draw- 
backs to its use. One objection to nitrous oxide-oxygen 
anaesthesia for the general physician is the cost of the ap- 
paratus and the cost, although not great, of the nitrous oxide 
and oxygen. Its use does need another physician to ad- 
minister it. 

The longest time I have given nitrous-oxide gas in an ob- 
stetric case is a little over six hours and there were absolutely 
no untoward symptoms. I now tell my patients that unless 
there is some good reason for not allowing them to have 
any anaesthetic, they can have nitrous oxide as soon as they 
think they want it. The secret of success in its use lies in 
the very prompt inhalation of the gas, the moment the pain 



132 CASE HISTORIES IN OBSTETRICS. 

begins. The maximum effect is not obtained unless this is 
done. Properly given there should be no cyanosis; very 
rarely slight excitation is caused. Usually the patient after 
a few pains very quickly appreciates the relief it gives her 
and from then on breathes it in quickly and quietly. As 
the pains become harder, not infrequently gas alone is not 
sufficient for relief and then ether is given through the same 
apparatus. Some patients who have had obstetrical ether 
with their first baby and gas with their second say they 
prefer the ether, for they do not, with the latter, wake up so 
completely and therefore the length of the labor does not 
seem so great. 

Again and again I have carried out normal deliveries and 
done low forceps under gas with but a very small amount of 
ether; the patients have all said that they did not consider 
the labor at all hard and that they never should dread a 
second. 

In cases in which gas is not satisfactory, the cause I be- 
lieve to be usually in the patients themselves, — they are 
apprehensive and will not do at once as they are told. In 
these cases encouragement and, if delivery is not imminent, 
the use of morphia will greatly help them to take the gas 
properly. When a patient realizes that her pains will be 
greatly relieved she faces her labor with much greater for- 
titude. 



SECTION IV. 
FORCEPS. 

Case 15. Low Forceps. Occiput Fully Rotated. 
Patient is referred on May 17th to me for care during delivery. 
Up to the present time she has been in charge of her family 
physician. She is twenty-eight years old and has never had 
any serious illness. Her last menstruation began on August 
31st making delivery due about the loth of June. She has 
had a normal pregnancy. Palpation of the abdomen to-day 
shows an average-sized baby lying in a left position. Head 
is freely movable at the brim but by the fourth manoeuvre 
it can be sunk into the pelvis. Fetal heart is 120 in the left 
lower quadrant. Measurements of the pelvis show crests 
27.5 cm., spines 25 cm., external conjugate 21.5 cm. Blood 
pressure is 120. She apparently is in excellent condition. 

May 31. Vaginal examination to-day shows the biparietal 
well through the brim. Cervix is soft and partially taken 
up and the os admits one finger. Promontory cannot be 
reached. Curve of the sacrum is apparently normal. The 
contour of the pelvis is normal. The closed fist can be 
readily pushed between the ischial tuberosities. Perineum 
is firm. 

June 8. Telephone from the nurse at 3 a.m. saying labor 
had started at one o'clock and that the pains now were 
coming practically continuously though their strength was 
irregular. I reached the patient at four and found her 
having contractions every minute or minute and a half. 
Uterus was relaxing well between pains. It was not tender. 
Position made out to be O. L. A. By the fourth manoeuvre 
the biparietal was found well through the brim. Fetal heart 
heard in the left lower quadrant, 120 to the minute. Patient's 
pulse is 70. There is no history of rupture of the membranes. 

Vaginal examination at 4 : 30 : There is no show. Peri- 
neum much less rigid than a week ago. Head is on the level 

^33 



134 CASE HISTORIES IN OBSTETRICS. 

with Spines of the ischia. Sagittal suture is in the antero- 
posterior diameter. Neither fontanelle felt. Posterior lip 
of the OS can just be reached. Anterior is prominent and 
slightly edematous. No membranes are felt. 

At the next pain I pressed upward trying to push back 
this edematous anterior lip and to a great extent was success- 
ful. At 4: 45 she asked for and was given ether as the pains 
were coming very hard with intervals of only one minute 
and lasting a minute and a half. Her pulse was 80. Fetal 
heart 120. The uterus was soft between pains and not 
tender. At 5:30 she began to bear down with each pain 
and occasionally the slightest bulging was seen. Fetal 
heart the same, patient's pulse 86. No change in the type 
of pains. No tenderness of the uterus. 

From now until 6:30 she worked hard but there was no 
apparent progress. The patient's pulse now was 100. I 
decided to deliver her because of the lack of progress and the 
rising pulse. Preparations were at once completed. An 
etherizer was sent for and as soon as he came the patient was 
etherized and carefully prepared. Leg holder was used to sup- 
port the legs. I attempted to catheterize the patient but the 
head was so low that I could not obtain any urine. Peri- 
neum thoroughly stretched and vaginal examination showed 
that the posterior fontanelle was at the arch. Sagittal 
suture in the antero-posterior diameter. The ear I did not 
feel. The anterior lip of the cervix was not felt. The left 
blade was carefully applied hugging closely the side of the 
head. It was introduced opposite the left sacro-iliac joint 
and then swept up into position. The right blade was 
similarly applied but on the opposite side and brought into 
apposition with the first blade. Forceps readily locked and 
apparently an excellent application of the forceps was ob- 
tained. Fetal heart was heard beating regularly by the 
etherizer. With very slight traction downward the scalp 
came into view; the circulation was found to be excellent. 
A very slow delivery then done. With gradual extension 
the brow and face came over the perineum and the head 
was readily delivered. The baby cried at once before the 
shoulders were born. Slight traction on the neck brought 



FORCEPS. 135 

the anterior shoulder to the arch and then by lateral flexion 
upward the perineal arm was delivered and the anterior 
followed. The baby cried lustily. The cord when it stopped 
pulsating was .tied and cut and the baby was put away. 
There was no tear of the perineum. Half an hour after the 
baby was born the placenta was delivered intact with all 
the membranes. The uterus acted well and no ergot was 
given. There was no bleeding and she was cleaned up and 
a sterile pad put in place. Put back to bed with a pulse of 
72 and at eight o'clock was out of ether and in excellent 
condition. The baby weighed seven and a half pounds. 

Evening visit: Patient has a temperature of 994"^, pulse 
80. Uterus well contracted, three finger breadths below the 
umbilicus. Lochia normal. Voided fifteen ounces of urine 
this afternoon. Milk is in the breasts and the baby is to be 
put to each breast for three minutes every four hours. 

June 10. Milk came in very gradually and caused the 
mother little discomfort. Temperature normal. Pulse 72. 
Baby is nursing well on the breast for five minutes every two 
hours. 

The convalescence was absolutely normal. Temperature 
never rose above 99°, pulse not over 80. Uterus involuted 
slowly and could be palpated from above until the tenth day. 
Lochia remained red until the sixteenth day. The foot 
exercises were begun on the tenth day and the leg exercises 
on the fourteenth. There was no apparent increase of the 
lochia from them. 

Patient got out of bed on the twenty-first day and walked 
about her room. Vaginal examination in the fifth week: 
No discharge. No tear of the perineum. Slight bilateral 
tear of the cervix. Uterus normal in position and freely 
movable. No tenderness found in the pelvis. Baby is doing 
well, gaining steadily. Umbilicus is solid and no bulging. 
Movements are normal. Patient is discharged to her own 
doctor. 



136 CASE HISTORIES IN OBSTETRICS. 

Case 16. Low Forceps. Irregular Fetal Heart. 
Patient is seen for the first time November 6. The last 
menstruation was April 21. During the first months of her 
pregnancy she had been under the care of no physician. 
She has had two miscarriages and was curetted after the 
last one. Except for these miscarriages the cause of which 
she does not know she has never been in bed sick. She was 
advised regarding the remainder of her pregnancy. Exam- 
ination of the urine showed it to be normal. She is passing 
three pints of urine and her bowels are moving regularly 
without medicine. 

January 18. Patient telephones that she is having severe 
pain in the right side of her back, low down, which is bother- 
ing her on walking and on sudden turning. Palpation over 
the right sacro-iliac joint showed definite tenderness. There 
was distinct limitation of motion on left lateral flexion and 
on bending forward. Flexion of the right hip with extension 
of the lower leg causes pain in the right sacro-iliac joint. 
Palpation of the abdomen shows a fair-sized baby. Fetal 
small parts on the left, and fetal heart best heard in the left 
lower quadrant. At that time it was noticed that the heart 
was irregular from the eighth to the tenth beat being dropped. 
Fetal heart not counting the dropped beats was 128. Pel- 
vimetry gives the following results: crests 29 cm., spines 
25 cm., external conjugate 22 cm. Diagnosis of the condi- 
tion of the joint is undoubtedly a relaxed sacro-iliac joint 
due to the pregnancy. 

I advised that her back be strapped with adhesive plaster 
or that she stay quietly at home for a few days and rest that 
joint. She had been going about a great deal and up and 
down stairs many times. If rest did not give her comfort 
I said she ought to be strapped at once. She chose to stay 
quietly at home. 

January 21. She telephones that she had to walk a great 
deal yesterday and that the right side was again paining her. 
Pain was so severe that last night she did not sleep. She 
now consented to be strapped. As soon as she was strapped 
she obtained immediate relief. 

January 26. Vaginal examination showed the head in 



FORCEPS. 137 

the pelvis. Cervix soft and not dilated or taken up. Is- 
chial tuberosities are not close. Ischial spines are not pal- 
pated. Angle of the symphysis apparently normal. Fetal 
heart 130, left lower quadrant and absolutely regular. 

February 10. The patient pulled off the strapping to-day 
as it was irritating her skin. She apparently is comfortable 
without it. 

February 12. Patient started up in labor at half-past 
ten this morning with pains coming every fifteen minutes, 
very slight, although there are definite uterine contractions 
present. Fetal heart, the nurse telephoned, was regular at 
130. At twelve o'clock fetal heart was listened to and it 
was found to drop every eighth to tenth beat, as it did three 
weeks before. Membranes were unruptured and the pains 
were now coming every six to eight minutes and lasting one 
minute. At 12:15 fetal heart was listened to and the beat 
was dropped only once in twenty beats. At one p.m. I exam- 
ined her by vagina and the head was found to be on the peri- 
neum. Cervix was thick. Os was dilated two and] a half 
inches. Membranes were unruptured. At 1:15 fetal heart 
listened to and it was found again to be slightly irregular. 
An assistant had been sent for. Preparations for delivery 
were completed. At 1:30 the fetal heart was found to be 
absolutely regular at 130. From then on until four o'clock 
there was absolutely no variation in the fetal heart. Mem- 
branes were still unruptured. At four o'clock I listened to 
the heart and found it to be 100 and a few moments later it 
rose to 144. I therefore decided to operate and deliver the 
patient at once. Probability is that the patient must be 
fully dilated by this time, as the pains had been coming 
every two minutes for the last two hours. I advised ether 
and delivery in the interests of the baby. Accepted by the 
husband. Patient prepared in the usual method, ether- 
ized, lithotomy position, catheterized. Perineum thoroughly 
and completely dilated. Os was fully dilated, only a small 
thin edge of the anterior lip could be felt. I ruptured the 
membranes and meconium stained liquor came away. The 
head was low and in making a definite diagnosis of the posi- 
tion, I found a loop of cord down beside the head. Cord 



138 CASE HISTORIES IN OBSTETRICS. 

was found pulsating regularly when I first felt it but a mo- 
ment afterwards it began to beat irregularly. The question 
now came up whether to push back the head and do a version 
or put forceps on to a low head with care so the cord would 
not be caught. I determined on the latter procedure. The 
head was fully rotated. The left blade of the forceps was 
put on hugging the head very closely, and the cord was felt 
pulsating outside the blade. Right blade was then put on 
without any difficulty. Blades locked well and as they were 
locked the etherizer listened to the fetal heart and found it 
beating very irregularly. The head was quickly brought 
into sight and by pressure on the scalp it was seen that the 
circulation was fair and therefore the head was brought 
slowly over the perineum. The head delivered, the face 
was blue and the remainder of the delivery was not hurried. 
The baby showed slight asphyxia but did not cry well for 
some minutes. The liquor which came away after the birth 
of the baby was meconium-stained and in the vagina was a 
large mass of meconium. 

Examination of the perineum showed a slight internal 
tear in the median line which was at once repaired with two 
chromic catgut sutures. There was no external tear. ^ The 
placenta was delivered thirty minutes after the birth of the 
child intact with all the membranes. The uterus did not 
act well but constantly relaxed, contracting, slowly and 
inefficiently. Ergot was given subcutaneously and ice was 
put to the fundus. The patient's pulse now was 120, but of 
good volume and tension. She was cleaned up, sterile pad 
put over the vulva and put back to bed. 

The uterus was constantly held and gradually began to 
act better. There was much more than a normal amount of 
bleeding, but not enough to call a hemorrhage. A half 
hour after the first dose of ergot was given a second was 
injected. The pulse steadily dropped in rate and one hour 
after the delivery was 76 but the uterus was acting only 
fairly well. Careful watch was kept on the uterus and it 
was not allowed to fill up. Two hours after the delivery it 
began to stay well contracted and there was from now on 
only the normal amount of flowing. She made an uninter- 
ruptedly good convalescence and nursed her baby well. 



m 



FORCEPS. 139 

Case 17. Occiput Right Posterior. Low Forceps. 
Rigid Coccyx. Patient is seen for the first time May 9th. 
This is her first pregnancy. She is thirty years of age, has 
always lived an out-of-door life and has ridden horseback a 
great deal. She has never been sick. Her last menstruation 
began on September 2nd. The August period was perfectly 
normal and there was no October period. She has had a 
normal pregnancy in all respects. Her confinement is due 
between the sixth and twelfth of June. She is living out of 
town and plans to come in town to a hospital for delivery. 

Palpation shows a fair-sized baby lying in a right position. 
Fetal heart is 120 in the right lower quadrant. Measure- 
ments are normal. 

Vaginal Examination: — Head is well down in the brim. 
Promontory cannot be reached. Contour of the pelvis nor- 
mal. Coccyx is noticeably forward and rigid. Outlet is 
normal. 

June 9. Came to the hospital six days ago. There is no 
sign of labor. She is perfectly comfortable. Palpation shows 
the head firmly fixed in the brim. A large baby, weight esti- 
mated at eight pounds and a half. She is worrying because 
she does not feel the baby kick. Fetal heart listened to and 
found but could not be counted because of the loud placental 
bruit. 

June 19. There is still no sign of labor and she wants to 
go home and be confined there. To-day she asked me, if in 
case I knew there had been no possibility of pregnancy be- 
ginning right after the September period, would it make any 
difference in calculating the date of confinement? I told 
her that it would. She then said that she and her husband 
were on a horseback trip in the mountains of Mexico and 
they especially avoided any intercourse until they had fin- 
ished this trip. I then counted up two hundred and eighty 
days from the earliest possible time pregnancy could have 
begun and the date was June 23rd. As she had to look for- 
ward to another week at the hospital she decided to take 
her nurse home with her and be confined there. Vaginal 
examination to-day showed the biparietal to be well through 
the brim. Cervix is soft and nearly flush with the vagina. 



140 CASE HISTORIES IN OBSTETRICS. 

As I saw no reason to expect a difficult delivery, the only 
questionable obstacle at all being the rigid coccyx, !_ agreed 
to her going home. 

June 25. Patient at 8 p.m. started in labor. Pains began 
every fifteen minutes and lasted thirty seconds. At nine 
o'clock pains began to come every five minutes lasting one 
minute and occasionally one and a half to two minutes. At 
ten the pains were coming every three minutes, lasting two 
minutes. The uterus was soft between pains. Fetal heart 
126, best heard just below the umbilicus. The patient thinks 
some waters came away when she was at dinner but she is 
is not sure. The nurse says that her underclothes were very 
slightly wet. Probability is that the membranes ruptured 
at the onset of labor. The patient's pulse is 80. 

Palpation : — The fetal small parts are distinctly felt on 
the patient's left and the fetal back is on the right making 
the position a probable O. D. P. 

Vaginal Examination at 10 p.m: — Os uteri, edge thin and 
dilatable, and dilated to two-thirds. The head is well in the 
pelvis. There is slight pitting of the scalp when the examining 
fingers pressed in on it. Pains continued coming every three 
minutes, lasting one to one and a half minutes. Fetal heart 
was listened to every half hour and there was no variation. 
At half -past eleven she began of her own accord to bear 
down, but the perineum did not show the slightest sign of 
bulging and there was no show. She kept this up for one 
hour and there was no material progress made. Fetal heart 
now listened to every fifteen minutes and remained good, 
126 to the minute. Examination at quarter of one showed 
a large mass that readily pitted when the examining finger 
was pressed into it and beyond this mass was felt the fetal 
head which had not come down any since the first examina- 
tion. Sutures in the head could not be felt. The os was fully 
dilated. In nearly three hours the patient had not gained 
anything in the descent of the head and a large caput succeda- 
neum had formed. Mother's pulse was 98. I decided then to 
deliver the patient for the following reasons : For three hours 
there had been no appreciable descent of the head in spite 
of excellent labor, a large caput succedaneum was forming 



FORCEPS. 141 

and the maternal pulse was rising. The patient was ether- 
ized, placed in moderate lithotomy position and carefully 
scrubbed up. Catheterized. Perineum thoroughly dilated. 
Examination then showed the head to be pushed down 
firmly against the coccyx, the sagittal suture is in the trans- 
verse diameter and the occiput is on the right showing that 
the position had been an O. D. P. and that now it is partially 
rotated. The posterior lip of the os was not felt. The 
anterior could be felt but was thin and soft. A large caput 
was present. The head was then pushed upwards slightly. 
The right blade was passed along the hollow of the sacrum 
until it was in place over the baby's right ear. The left 
blade was then passed along the left side of the pelvis over 
the face, swung upwards and over the brow until it was 
opposite the first blade. The forceps were then readily locked. 
The tips of the forceps were pointing to the occiput, the 
transverse diameter of the forceps was at right angles to the 
transverse diameter of the pelvis. 

The fetal heart now listened to by the etherizer and found 
to be regular. The first traction brought the head down 
again on the coccyx. With hard traction and rotation for- 
ward the head gradually descended. As soon as I was able 
to sink the occiput low enough under the arch, overcoming 
gradually the resistance of the coccyx, the remainder of the 
delivery was very simple. Pressure on the scalp showed 
excellent circulation and the delivery of the brow over the 
perineum was accomplished very slowly. There was no dif- 
ficulty with the shoulders or body. The baby cried at once, 
and as soon as the cord stopped pulsating it was clamped 
and cut. There was no external tear of the perineum. There 
was a slight tear on the patient's left and another on the 
right perineum. Each was sewed up at once with three chro- 
mic catgut sutures. The placenta came away intact with all 
its membranes twenty minutes after the birth of the child. 
There was no bleeding. The patient w^as in excellent con- 
dition, pulse no. The baby weighed eight pounds. 

July 20. The patient got up on the twentieth day and 
walked about the twenty-first. Marked ''pins and needles" 
in her feet when she first walked although she did her exer- 



142 CASE HISTORIES IN OBSTETRICS. 

cises faithfully. Abdominal wall is very flabby and the exer- 
cises for strengthening these muscles are to be continued 
night and morning. The baby is nursing and doing splen- 
didly. 

August 20. Patient has done uniformly well and now is 
in excellent condition. Vaginal examination : — No dis- 
charge present. Body of the perineum is excellent. The 
tear on the left is evident and did not heal well. Tear on 
the right well healed. Slight stellate tear of the cervix. 
Uterus normal in size and position. No tenderness anywhere 
in the pelvis and palpation of the coccyx does not cause her 
any pain. Baby is gaining and in excellent condition. 
Patients discharged to the family physician. 



FORCEPS. 143 

Case 18. Partial Manual Dilatation of the Os 
Uteri. Low Forceps. July 23. Patient is a primigrav- 
ida, 23 years of age. She has been under the care of her 
physician in another city up to the present time and has 
only recently moved here. She is seen to-day for the first 
time. She says that she has been perfectly well during her 
pregnancy and that all urinary examinations have been nor- 
mal. The beginning pf her last menstruation was October 
17th making delivery due about July 27th. She has always 
been well with never any serious illness. She was at once 
examined because of the nearness of her approaching labor. 
Palpation shows a good-sized baby. The back is on the 
left. Small parts definitely made out on the right. Head 
is engaging at the brim but the biparietal is not yet through. 
Fetal heart is in the left lower quadrant, 130 to the minute. 
Crests 27 cm., spines 24 cm., external conjugate 20 cm. 
Vaginal examination : Introitus tight. Perineum rigid. Cer- 
vix soft and partially taken up. No dilatation of the os. 
The head from below can be readily pushed up. Promon- 
tory cannot be reached. Contour of the pelvis is normal. 
Ischial spines are prominent. Arch of the symphysis is nor- 
mal. The closed fist can be placed between the ischial tuber- 
osities. Specimen of urine obtained and examination of it 
was normal. 

August 7. Telephone from the patient at 7:30 p.m. that 
she was having pains every four minutes and that they were 
lasting nearly a minute. She went at once to a private 
hospital. I saw her at 9 p.m. and she says that she has been 
uncomfortable the greater part of the afternoon but definite 
pains did not begin until about 6:30. Palpation shows posi- 
tion the same as before but now the head is well down in the 
pelvis. Fetal heart is 120, maternal pulse is 80. Patient 
was having very hard pains every two minutes lasting one 
and a half minutes. She cried out with the beginning of 
each one and then would bear down. Vaginal examination 
at 9:30 showed that the cervix is taken up but there is no 
dilatation of the os. The lower anterior uterine segment is 
very thin. A finger tip can be passed through the os and no 
forewaters can be made out. The biparietal diameter is 



144 CASE HISTORIES IN OBSTETRICS. 

through the brim and the head is firmly wedged down into 
the pelvis. She was at once given primary ether and the os 
dilated up manually to two inches. Dilatation was very 
readily accomplished by gently separating the fingers of the 
examining hand. She came out of ether very quickly but 
there were no pains for half an hour. The uterus was soft. 
Fetal heart 130. Much show of bright blood. Pulse 90. 
At 10:30 the pains were coming every five minutes lasting 
one minute. She acted badly throwing herself about and 
crying out loudly. Probably because of the ether she had 
lost control of herself and she made no effort to regain her 
control. The fetal heart remained 130 and regular. The 
uterus was not tender and was relaxing well. At eleven 
thirty she began again to bear down with each pain. Her 
pulse 80, the fetal heart the same and the uterus was acting 
well. At twelve o'clock very light obstetrical ether was given 
her. At 1 130 a.m. the pains began coming at two-minute 
intervals and lasted a minute and a half to two minutes be- 
fore the uterus became fully relaxed. The fetal heart now 
found to be 148 and the patient's pulse had risen to 96. She 
now had a constant desire to bear down and the uterus was 
relaxing very slowly and the lower uterine segment was dis- 
tinctly tender. I decided to deliver her at once because of 
the action of the uterus, its beginning tenderness, the rise in 
the fetal heart and the slight rise of her own pulse. 

Preparations had been begun for operative interference 
and were quickly completed. She was etherized and care- 
fully scrubbed up after she was in a moderate lithotomy posi- 
tion. The legs were held by two nurses. The vagina was 
wiped out carefully with 70% alcohol and then an examina- 
tion made. The os was now three inches dilated, thin and 
dilatable. A large caput was present. Head was on the 
perineum. She was then catheterized and a small amount of 
urine obtained. The perineum was slowly and thoroughly 
dilated ; gradually the whole hand was worked into the vagina. 
The head was pushed up a little way and the cervix dilated 
as much as possible without displacing completely the head. 
The position O. L. A. was confirmed. 

The right hand in the vagina the left blade was passed 



FORCEPS. 145 

along the gloved hand, the fingers touching the cervix and 
the blade placed inside the cervix on the side of the child's 
head. The right hand removed and the fingers of the left 
hand inserted into the vagina. The cervix was felt and the 
blade passed close to the head and placed opposite to the 
left blade. The forceps locked at once. Slight traction 
downwards and the head descended putting the cervix on 
the stretch. The anterior and then the posterior lip was 
pushed back against the oncoming head. It was evident 
there was no bony resistance to the delivery. With consid- 
erable amount of traction the posterior and then the anterior 
lip of the cervix slipped back. Head then began to bulge 
the perineum and a slow extraction was done. The occiput 
was sunk well down under the symphysis and no attempt at 
extension was made. The pressure on the baby's scalp 
showed that the circulation was good and the delivery was 
not hurried. Extension gradually took place and the line of 
traction was slowly changed. Forceps were kept on until the 
delivery of the head was completed and then taken off. The 
occiput restituted to the left. The cord was felt for and was 
not about the neck. With slight traction on the head the 
anterior shoulder came to the arch and was delivered and the 
perineal arm followed readily. The body was born by lateral 
flexion. The baby cried at once. Cord was not pulsating 
and was clamped and cut and the baby put aside. The 
caput was large. The uterus acted well and there was no 
bleeding. Perineum shows an internal tear on the patient's 
left and also a median external tear. They were repaired at 
once by three chromic catgut and two silkworm-gut sutures. 
Placenta was delivered in twenty minutes intact with all the 
membranes and no bleeding. Mother was in good condition 
with pulse of no. Uterus acted well. Baby weighed 8 lbs. 
and examination of it showed it to be normal. 

August 9. Evening visit. Temperature found to be 102° 
and pulse 120. Examination of the heart and lungs nega- 
tive. Abdomen not distended. Uterus well contracted, 
three finger breadths above the symphysis and not tender. 
Lochia normal in amount, red in color and normal odor. 
She looks bright. Does not act sick. Secretion present in 



146 CASE HISTORIES IN OBSTETRICS. 

the breasts. Baby was put to the breast twice to-day and 
took hold well. I can find nothing to account for the rise in 
temperature. She is not, in my opinion, septic. I decided 
to let her alone and await developments. On making in- 
quiries of the nurse for any possible cause for temperature I 
found that four members of her family had come to the 
hospital to see her and had insisted upon going by the nurse 
and seeing the patient and the baby. 

August 10. Temperature this morning 100.8°. Pulse has 
dropped to 90. Examination showed her to be in absolutely 
normal condition. Temperature to-night 98.6° and pulse 84°. 

Thereafter she made a perfectly normal convalescence with 
her pulse gradually dropping to 70. Temperature remained 
absolutely normal. The milk came in slowly on the third 
day and the baby has been nursing regularly ever since. 
Stitches were taken out on the tenth day and apparently a 
good result. The baby has done consistently well. The 
umbilicus presents a large, thick stump, and is moist. It was 
touched on the tenth day with the silver nitrate stick, wiped 
off with alcohol and powdered with subgallate of bismuth. 

August 20. Umbilicus looks very much better. Now only 
a small granulation area. 

The patient got out of bed on the twenty-first day and 
went to her summer home ten days later. Vaginal examina- 
tion the day before discharge shows excellent result on the 
perineum. No bulging on bearing down. Tear on the right 
has healed. On the right side at the vault is a distinct band 
running from the cervix to the vagina showing that she had 
a severe tear of the cervix. Uterus is normal in position and 
well involuted. No tenderness present in the pelvis. No 
vaginal discharge. The baby's umbilicus is healed. 

Note: — The temperature on the night of the ninth I 
considered first due to sepsis but I could find no other signs 
of infection. It is probable that this temperature was due 
to absorption at the cervical tears together with the ex- 
citement of seeing her family. There is no question but that 
excitement may give a fleeting temperature. The diag- 
nosis first, however, is sepsis. I chose a waiting policy and 
had no cause to regret it. 



FORCEPS. 147 

Case 19. Occiput Left Posterior. High Forceps. 
Double Application. Patient is seen for the first time July 
20. Her last period was April 22. She will be due for 
delivery the last week of January. Except for slight amount 
of acid eructation she is in excellent condition. Milk of mag- 
nesia which had been given her gives her no relief. She was 
given the regular advice about pregnancy. For the acidity 
she was given the sodium bicarbonate, bismuth subnitrate 
and beta napthol mixture. She went through her pregnancy 
absolutely normally with no discomfort until December 13th 
when she telephoned that she was having much pain in the 
lower abdomen especially on walking, on sudden movements 
and on going downstairs. Examination showed that pres- 
sure over the symphysis caused her distinct pain and that 
with pressure over the iliac crests the same pain could be 
elicited that she complained of on walking about. There 
was no tenderness over either sacro-iliac joint. 

Diagnosis : Relaxation of the symphysis pubis. 

Treatment advised was broad adhesive strapping about 
the iliac crests and above the trochanters to hold the sym- 
physis tight. This was at once put on and as soon as she 
was about, she found she obtained perfect relief. 

January 4. Palpation shows a large abdomen. Much fat 
and apparently considerable amount of liquor present. Po- 
sition is O. L. A. Head freely movable at the brim. Fetal 
heart 130 in the left lower quadrant. The baby will weigh 
about 7§ pounds. Intercostal diameter 30 cm., interspinous 
26 cm., external conjugate 21 cm. Vaginal examination, in- 
troitus large. Promontory cannot be reached. Pelvis is 
ample. Pubic arch is normal and the closed fist can readily 
be pushed between the tuberosities of the ischia. 

January 10. The strapping to-day was removed. It has 
caused marked irritation on both hips. 

January 11. Has but very little discomfort at the sym- 
physis. Only present on going up and downstairs. 

January 13. Patient was awakened this morning at i .-30 
by being flooded with water. She was very much alarmed 
by it and I saw her at once. Fetal heart listened to and 
found to be perfectly regular in left lower quadrant. Head 



148 CASE HISTORIES IN OBSTETRICS. 

was not engaged. No pains. As the head was not engaged 
and as the gush of liquor apparently had been great I exam- 
ined her at once and found the os not dilated. Cervix about 
half taken up. Head high and not engaged. No cord could 
be felt. Her nurse was sent for and she was kept in bed as 
there was constant oozing of liquor. She slept the rest of 
that night and had no pains. 

January 14. At 3:30 this morning she began having 
very slight contractions about once in twenty minutes, just 
enough to wake her up and prevent her from sleeping. She 
was given fifteen grains of chloral by rectum and this was 
repeated in one hour. She slept from then until seven 
o^clock when she was awakened by the contractions which 
came every twenty minutes, lasting thirty seconds. She 
dozed between the pains. From ten in the morning until 
noontime she had pains every seven minutes lasting one- 
half to three-quarters of a minute. Fetal heart remained 
regular at 128. Examination at twelve showed that she 
was then dilated the size of a silver dollar; biparietal was 
nearly through the brim. At 2 o'clock she began to act 
badly and to throw herself about the bed and beg for ether. 
The pains began to come distinctly harder and at three 
minute intervals, lasting one-half a minute. At no time did 
they last more than forty seconds. Examination at four 
showed that the head was no lower. She now was dilated 
three inches. 

Pains from now on became very much more severe and 
the uterus showed slight tendency to stay tonically con- 
tracted. When palpated at 4:30 the whole uterus was very 
slightly tender but was relaxing well. Obstetrical ether was 
now started. She was standing labor poorly and her pulse 
had risen to no. Fetal heart remained at 130. The pains 
for the last hour came at seven minute intervals and 
lasted but thirty seconds. Fetal heart remained the same. 
The uterus did not relax fully but the tenderness did not 
increase. The head from palpation seemed a little lower. 
Her pulse was 120. 

I decided now (6 p.m.) to deliver her because of her rising 
pulse; the tendency of the uterus not to relax fully; the 



FORCEPS. 149 

slight tenderness of the uterus and because of the poor type 
of labor she was in. 

Operation. Etherized. Lithotomy position. Prepared. 
Perineum carefully dilated. Os found to be fully dilatable 
and thin. Position by the contour of the occiput and the 
ear was found to be O. L. P. Well flexed. In determining 
the position the head went up above the brim. Some three 
inches within the os was found a definite thickening of the 
uterus which extended completely about it. It dilated very 
readily. That it was a beginning contraction ring there 
could be no doubt. 

My right hand grasped the occiput and turned it from left 
to right making it an O. L. A. With pressure by the ether- 
izer from above on the head I applied the left blade to the 
left side of the fetal head. The hand was then removed and 
the right blade passed in along the left hand; in attempting 
to place this blade the head slipped back to a posterior posi- 
tion. I then took off the forceps and applied the left blade 
again to the fetal head in the posterior position. The right 
was then readily placed. The forceps locked well. Fetal 
heart listened to by the etherizer and found to be regular. 

Tentative traction applied and the head readily came 
down. Several more tractions without much force brought 
the head to the perineum and it started to rotate. The sag- 
ittal suture was found to be just anterior to the transverse 
diameter. Forceps were now removed with the intention of 
reapplying them with the tips towards the occiput. Exam- 
ination now showed the sagittal suture in the left oblique 
diameter. The head had slipped back into a posterior posi- 
tion. I reapplied the forceps without attempting to rotate 
anteriorly the head. Traction downward combined with 
rotation forward brought the occiput to the arch and the 
forceps were completely reversed. They were now taken 
off and quickly reapplied to a fully rotated head. With very 
slight traction the head was then delivered. There was no 
trouble with the shoulders or the body. The baby cried at 
once and was in excellent condition. In a few moments the 
cord stopped pulsating and it was then clamped and cut. 
There was no bleeding to note. Patient's pulse was 120, of 



150 CASE HISTORIES IN OBSTETRICS. 

good volume. Examination of the perineum showed no ex- 
ternal tear. There was a small but deep internal tear in the 
median line; no other tears found. This tear was at once 
repaired with chromic catgut No. 2 sutures passed from the 
vaginal mucous membrane on one side to the base of the tear 
and out on the opposite side. Three such sutures were passed 
and brought the perineum into excellent approximation. 
These sutures were not tied until after the placenta was de- 
livered. Thirty minutes after delivery of the baby the pla- 
centa came away intact with all the membranes. The uterus 
acted well and there was the normal amount of bleeding. 
Patient's pulse when she was put back to bed was 120. She 
made a good recovery from ether and there was no vomiting. 

January 15. Temperature this morning 994°. Pulse 100. 
In excellent condition. Temperature to-night 98.6°, pulse 88. 
Has voided without difficulty. The baby weighed eight 
pounds. 

January 17. Bowels moved to-day by castor oil half an 
ounce followed in four hours by a suds enema. There is no 
milk in the breasts and the baby is put on a modified milk. 

January 30. Has made an excellent convalescence. Tem- 
perature at no time has been over 99.4° and the pulse not over 
94. To-day the evening temperature is 98.6° and pulse 78. 
She complains of inability to hold gas by rectum. Her con- 
trol of feces is perfectly good. 

February 13. Menstruation began to-day. Continued for 
five days and was of the same character as before her preg- 
nancy. 

March 9. The patient refuses to be examined vaginally. 
She says she feels perfectly well and that there is no vaginal 
discharge. She is nursing her baby and is going about ap- 
parently in better condition than ever before her pregnancy. 
She says that if she feels wrong in any particular she will be 
examined. She now has complete control of the sphincter 
in respect to gas. Her early lack of control was probably 
due to the stretching of the sphincter at delivery. 



FORCEPS. 151 

Case 20. Occiput Left Anterior. Edematous An- 
terior Lip of the Cervix. High Forceps. Telephone 
from the attending physician at 12:30 a.m., September 20, 
saying that he had a patient, a primapara, who had been 
in labor some thirty-six hours; membranes had ruptured 
two hours before the onset of labor, that the head is high, 
that she is now dilated two and a half inches and that he 
can feel a low attached placenta anteriorly and that when 
examined she bleeds more freely than he likes. 

I went as soon as possible to the patient. She is a large 
woman and is having pains every six minutes, lasting but 
twenty to thirty seconds. Her pulse is 110 and of good 
volume. Palpation of the abdomen shows a large baby. 
The uterus is firmly contracted on the baby, relaxes between 
pains very poorly and is tender on palpation. The position 
is not determined, but the physician says that definite fetal 
motions have been seen and felt on her right. Fetal heart is 
best heard in the lower left quadrant, 160 to the minute, a 
rise from 120 in the last three-quarters of an hour. 

Vaginal Examination : — Large introitus. Anterior vag- 
inal wall is edematous and the anterior lip of the cervix is 
felt low down in the vagina and is very edematous. The os 
is dilated two inches. The promontory is not reached. 
The head is firmly wedged at the inlet, but the biparietal 
diameter of the head is not through the brim. The examin- 
ing finger inside the cervix could feel no placenta. The 
anterior lip bled when touched. The probability is that it 
is this edematous anterior lip that the physician took to be 
the placenta. 

I advised that she be delivered at once because of the length 
of labor, because the uterus was becoming tonic, because it 
had already become tender, because of this edematous con- 
dition of the cervix, and because the fetal heart was going 
up. A guarded prognosis was given for the baby. 

The advice was accepted by the husband and the wife 
and preparations for delivery were completed at once. 

She was etherized, placed in lithotomy position and her 
legs supported by the Robb leg holder. She was scrubbed 
up after she was under ether. Catheterized, but no urine 



152 CASE HISTORIES IN OBSTETRICS. 

obtained. Perineum thoroughly and completely dilated man- 
ually. The anterior lip of the cervix was then seen low in 
the vagina, thick, edematous, bluish in color and it bled 
when touched. The dilatation of the cervix was slowly and 
carefully done. It readily stretched but it was felt to tear 
on each side. The closed fist was finally brought through 
the OS uteri three times, and it offered no resistance. 

The position was found to be an O. L. A. not rotated. In 
determining the position I felt the cord pulsating beside the 
head, regularly, though very rapidly. 

With my right hand in the vagina and my fingers reaching 
the cord I passed the left blade of the forceps into the vagina 
through the cervix, hugging the head closely. Thus placed, 
I removed my right hand and then with my left hand in the 
vagina I guided the right blade into position; the forceps 
locked with difficulty; the ends of the handles did not come 
well together. I examined again and found the cord was 
outside the forceps pulsating slightly irregularly. On the 
first traction the head came down slightly and it was at once 
seen that the thick edematous anterior lip was the obstacle 
to delivery. Traction downwards with the forceps and with 
pressure upwards on the cervix advance was gradually made. 
Slowly the anterior lip was pushed back behind the on-com- 
ing head. The posterior lip gave no trouble, and as soon as 
the cervix retracted, the head quickly came to the perineum. 
As soon as the scalp was in view pressure on it showed the 
circulation to be present and good. Extraction then was 
slowly finished, the circulation remaining good. There was 
no delay, however, in getting the head delivered. The cord 
was not about the neck. Traction at once on the neck 
brought the anterior arm down under the arch, and the 
shoulders were then delivered with but little trouble and the 
body followed. The baby gasped in a few moments, but it 
was some minutes before it cried, though the color was good, 
and the cord pulsated feebly. The cord was clamped and 
cut. Gradually the baby breathed better. Ether was very 
readily noticed on its breath when it breathed. 
I The uterus contracted well and there was no excessive 
bleeding. Examination of the perineum showed a deep sec- 



FORCEPS. 153 

ond degree median tear. The patient's pulse was now 120 
and only of fair character. One buried No. 2 chromic catgut 
suture was quickly placed including the deepest part of the 
tear, and then three silkworm-gut sutures rapidly placed and 
left untied until the placenta was delivered ten minutes later, 
intact with all the membranes. There was no bleeding and 
the cervix was not examined. The perineal sutures were now 
tied, the patient cleaned up, and a sterile vulva pad put in 
place and patient at once put back to bed. She was in fair 
condition, although she looked badly. Pulse remained for 
two hours 120, but improved in quality. The uterus remained 
hard and there was no bleeding. She came out of ether 
quickly. The baby weighed nine pounds and four ounces, 
and shortly after the delivery was in good condition. 

Telephone message from the physician in charge two weeks 
later states that the patient had made a good convalescence 
and that the baby had done well. 



154 CASE HISTORIES IN OBSTETRICS. 

Case 21. Occiput Right Posterior. Manual Dilata- 
tion. High Forceps. Patient is seen for the first time June 
first. This is her first pregnancy. Her last period was October 
26th. Normal in all its characteristics. She would, therefore, 
be due for delivery from the third to the ninth of August. 
She has had a perfectly normal pregnancy. 

July I. Palpation shows the baby to be of fair size, float- 
ing head in the right posterior position. Examination of 
the pelvis shows intercristal 28 cm., interspinous 25 cm., ex- 
ternal conjugate 20 cm. Fetal heart 120, in the right lower 
quadrant. Urine at all times has been normal. 

August I. Vaginal examination: — The perineum is soft. 
Cervix is partially taken up but no dilatation is present. 
The presenting part is readily reached but can be pushed out 
of the brim. Promontory cannot be reached. Ischial spines 
are not prominent. Contour of the pelvis is normal. Pubic 
arch is normal. Closed fist can be pushed between the 
tuberosities. Inclination of the pelvis is normal. 

August 6. Telephone from the nurse at 7 a.m. saying that 
the patient has been having pains since two, lasting only 
about ten seconds and coming every twenty or thirty minutes. 
I saw the patient at ten o'clock. She then was having a few 
contractions once in twenty minutes and lasting one-half a 
minute. The pain was very slight. At eleven they stopped 
entirely and she had a nap between two and four. At six 
o'clock pains started up again slowly every twenty minutes 
lasting one-half to three-quarters of a minute. At 10 p.m. 
they began coming regularly every ten minutes, lasting three- 
quarters of a minute. Palpation showed the biparietal was 
not through the brim but the head is firmly set in the brim. 
Uterus is relaxing well between pains. Fetal heart is 130 
and regular. Membranes are unruptured. 

August 7. She has had pains once every ten minutes last- 
ing one-half to one minute during the night. Had practically 
no sleep last night. At 7 a.m. she was examined and it was 
found that the os was one inch dilated, thin and rigid and 
cervix entirely taken up. Head lightly engaged but was dis- 
tinctly lower than at the examination a week ago. Anterior 
lower uterine segment was thin. Uterus was relaxing well 



FORCEPS. 155 

between pains and was not tender. Pulse no. Fetal heart 
130. I gave her 20 gr. of chloral by rectum and she obtained 
two hours sleep. From nine- thirty to eleven-thirty she had 
hard pains every three minutes lasting one minute to a 
minute and a half. Vaginal examination now showed that 
there had been no change except the fact that the lower 
anterior uterine segment was more markedly thinned. Pal- 
pation of the abdomen showed that the lower uterine seg- 
ment was distinctly tender although the uterus relaxed well 
between pains. Pulse 120. I then decided to deliver her 
because of the lack of progress in the dilatation, the rising 
pulse and the increasing tenderness of the uterus and the 
thinning of the lower uterine segment. 

The patient was etherized and placed in moderate lithot- 
omy position. Scrubbed up with soap and water. Washed 
off with corrosive solution and then 70% alcohol. The peri- 
neum carefully and slowly dilated as much as possible with 
the hand. The os was found to admit two fingers. It was 
gradually dilated until the middle finger could be pushed by 
the OS. Gradually the dilatation was increased so that the 
other fingers entered. Then with the fingers in the shape 
of a cone the whole hand was gradually passed by the os. 
The fist was now brought slowly down through the os and 
out of the vagina. There was then considerable bleeding. 
Pulse remained at 120 and of good volume. The hand was 
then passed into the vagina and through the os and the 
closed fist brought down slowly through the os three times. 
The last time the os grasped the fist very slightly. All 
through these manipulations the membranes did not rup- 
ture. They were now ruptured with the hand in utero and 
the position was found to be a right posterior. The left 
hand grasped the vertex about the occiput and very readily 
rotated it to an anterior position. The etherizer then pushed 
down on the head from above holding it at the brim. The 
right blade was now applied first without difficulty to the 
right side of the fetal head. The left hand now was taken 
out of the vagina. Pressure above by the etherizer kept up 
and the left blade was applied opposite to the right. This 
method of applying the forceps necessitated rotating the 



156 CASE HISTORIES IN OBSTETRICS. 

handle of the right blade about the handle of the left in order 
to lock the forceps. This was readily done and the forceps 
locked well. By the first tentative traction it was seen that 
the head descended a little. Fetal heart was listened to by 
the etherizer and found to be present and regular. Traction 
now by means of traction-rods brought the head readily to 
the pelvic floor. Much traction was necessary to sink the 
occiput below the arch. Care was taken to have the trac- 
tion intermittent and the handles also after each traction 
were unlocked. At each traction progress was made and as 
soon as the occiput was sunk well under the arch the re- 
mainder of the delivery was easy. 

Circulation of the scalp was seen to be excellent and the 
head was slowly delivered. The baby cried at once. There 
was no bleeding. The mother's pulse was 140 and she looked 
badly. The cord was clamped and cut and the baby put 
aside. 

The uterus acted well and twenty minutes later the pla- 
centa came away intact with all the membranes. There 
was a tear on the left pelvic wall and in the left perineum. 
No external tear. Three chromic catgut sutures No. 2 were 
placed and tied at once in the pelvic wall. The stitches 
were placed in the perineum but were not tied until the 
placenta was delivered intact with all the membranes forty 
minutes later. Patient's pulse continued to be 140. She 
was put quickly back to bed. She had marked shock and 
looked badly. She was pale. Her respirations were good. 
There was no bleeding. The uterus was hard. She soon 
began to come out of ether and to become restless, and 
was given at once morphia gr. | subcutaneously. Half hour 
after delivery the pulse became of poor volume and she was 
given subcutaneously strychnia gr. 1/20. Pulse at once im- 
proved and the improvement was held. She gradually picked 
up and two hours later she was in very fair condition with 
pulse of 1 10 and no bleeding. Baby was in excellent condition. 

The morning of the first day temperature was normal and 
pulse 100. Baby is crying and acts hungry and is put on a 
modified milk which satisfied her. Early the morning of the 
third day the mother was given half an ounce of castor oil 



FORCEPS. 157 

and two hours later had a very constipated movement which 
caused her much pain. She at once was given by rectum 
four ounces of oil and three hours later a suds enema. An 
excellent result without pain was obtained. Milk came in on 
the fourth day and she nursed her baby satisfactorily. Her 
convalescence was uneventful. Examination at the end of 
the fifth week showed an excellent result on the perineum. 
Stellate tear of the cervix. Uterus normal in size and posi- 
tion. No tenderness anywhere in the pelvis. Is up and 
about the house. Is nursing her baby regularly and is gradu- 
ally getting back to her routine. 

Since this pregnancy I have looked after her on two other 
occasions and each time she has had a normal delivery. 



158 CASE HISTORIES IN OBSTETRICS. 

Case 22. Occiput Left Anterior. Contraction Ring. 
High Forceps. Flat Pelvis. Patient is seen for the first 
time on Sunday, January 3rd, in the Out- Patient Department. 
She came in labor January 2nd about noontime, but did not 
send for the externe until January 3rd at 3 a.m. She was seen 
by the house officer at 9 a.m. and he then reported the con- 
dition to me as follows: — that he had just seen a colored girl 
who had been in labor twenty hours, in her first labor. 
Membranes were ruptured and the head high. Fetal heart 
120. Measurements, crests, 24 cm., spines 22 cm., external 
conjugate 17 cm. That the externe says the patient has 
made no progress in the last two hours. I saw her at once 
at her home, and it was in such a poor part of the city and 
the conditions for operative delivery were such that I felt it 
too great a risk to operate there and I therefore sent her at 
once into the hospital. She entered the hospital at 10:15 a.m. 
Vaginal examination then showed high presenting part, prob- 
ably occiput left anterior with a large caput. The promon- 
tory is readily reached and very prominent. The os is two- 
thirds dilated and is thin and dilatable. Palpation of the 
abdomen showed it to be rigid and the lower uterine segment 
is distinctly tender. It is a small baby under seven pounds 
in weight. Fetal heart is 140 in the left lower quadrant 
and slightly irregular. She had been in this condition 
now for some hours and I therefore advised immediate de- 
livery. The patient absolutely refuses to allow any * ' cutting ' ' 
operation. 

She was immediately prepared and when the preparation 
was completed she was etherized and placed in lithotomy 
position. Perineum thoroughly stretched and then the pel- 
vis more thoroughly examined. It is seen that the outlet of 
the pelvis is sufficiently large. The promontory is readily 
reached. The closed fist can only with difficulty be pushed 
between the promontory and the symphysis. After the cervix 
was thoroughly and completely dilated the hand was inserted 
into the uterus beyond the head and a tight contraction ring 
was felt at the neck, and the uterus beyond was firmly con- 
tracted on the baby. I decided to do a forceps delivery if 
possible, reserving craniotomy if necessary on a living child 



FORCEPS. 159 

as an operation of necessity. The position was O. L. A. 
The left blade was carried carefully in and placed on the 
left ear as nearly as was possible. The assistant held firmly 
the head down on the inlet and the right hand was with- 
drawn from the vagina and the left hand inserted and the 
right blade applied along the right sacro-iliac synchondrosis 
and swept up into apposition to the first blade. The forceps 
locked readily and apparently it was a fair application. 
Tentative traction showed that the forceps did not slip and 
on the second traction it was seen that the head came down 
and entered slightly into the brim. The anterior lip of the 
cervix came down in front of the head and with much pres- 
sure my assistant pushed it backwards. Walcher's position 
was then used and seemingly the head advanced more with 
this position. After the fourth traction the head gave a 
sudden jump as if it had gone by some obstruction. My 
explanation of it was that the head had gone by the prom- 
ontory. Examination showed this to be true. The head 
was now well within the pelvis. From now on the head 
readily came down and there was no trouble with the re- 
mainder of the delivery. As the head was delivered the 
eyes were wiped out. The cord was felt for but not found. 
Traction downwards on the head and the anterior arm came 
under the symphysis and the body of the baby was then de- 
livered. Cord was found pulsating slowly and the baby was 
in pallid asphyxia. Cord was clamped at once and the baby 
given to an assistant to resuscitate. There was a slight 
perineal tear with a slight bilateral tear of the cervix which 
was not repaired. Perineal tear repaired at once with two 
silk worm gut sutures. Placenta was delivered twenty min- 
utes later intact with all the membranes. She stood the 
operative delivery well and went off the table with a pulse 
of 120. There was no bleeding and the uterus remained 
well contracted. Examination of the baby shows a linear 
bruise with marked depression over the left eye. Forceps 
mark is readily made out over the left ear and the right 
frontal prominence showing that the right blade was swung 
up too far. The damage to the left eye could in no way 
have been done by the forceps blade and was undoubtedly 



l60 CASE HISTORIES IN OBSTETRICS. 

caused when the head came by the promontory. The baby 
soon cried well and breathed satisfactorily. 

January 4. Mother in excellent condition. Temperature 
99°. Pulse 100. The baby is crying poorly. The left eye 
is markedly edematous and the upper lid is slightly everted. 
The linear depression running from the left eyebrow to 
the frontal suture is marked. The baby is in very poor 
condition but there are no definite symptoms of cerebral 
hemorrhage present. 

January 5. Baby became distinctly worse during the night. 
Holds his head with marked retraction and the body arched. 
Anterior fontanelle is tense and level with the parietal bones. 
Posterior fontanelle also tense. Left eye is protruding and 
conjunctival hemorrhage evident. Tension of the left eye 
markedly increased. Right side of the face apparently nor- 
mal. Motions of the child not characteristic. Pupil of the 
left eye does not contract. Knee jerks are equal and present. 
Baby's temperature 102° by rectum. Pulse 120. When the 
baby is touched he cries out. Spit up a small amount of 
blood. Diagnosis: Cerebral hemorrhage. Condition has be- 
come so grave that there is no question of any operation. It 
died early in the morning of January sixth. Mother made 
an excellent convalescence and went out of the hospital well 
om the fourteenth day. She was advised on going out, to 
place herself, if she ever became pregnant again, under our 
charge early, so that we could follow the size of the baby 
and be guided as to what would be advisable. (See Cases 35 
and 36.) 



Stimmary of the Technique of Forceps Delivery. 

The preparations for an operative delivery are the same as 
for a normal delivery, with the addition of a pair of forceps 
in the instrument layout. I boil my forceps for every de- 
livery so, in fact, there is no change. The patient is prepared 
in the same way. The position in this country is usually the 
dorsal with the legs held either by a leg holder or by assistants, 
trained or untrained, as the case may be. If the dorsal posi- 
tion is used, do not put the patient in the exaggerated lithot- 



FORCEPS. l6l 

omy position because in this position the perineal muscles 
are made more tense than if the legs are simply held at right 
angles to the body. One's inability to change the position 
of the legs without difficulty is the one objection to the Robb 
leg holder. If the leg holder is used towels must be put at 
the popliteal spaces and behind the neck in order to keep 
unnecessary pressure from the legs and neck. More than 
once have I heard patients bitterly complain of pain from 
pressure at these points after an operative delivery when these 
precautions have not been taken. 

For every operative delivery an anesthetic must be used. 
Whether it is ether or chloroform depends entirely upon how 
the individual physician feels. I know of no valid reason 
why ether should not be used. Recent experimental work 
would make it appear that chloroform is a source of danger. 
It has no real advantage over ether and I therefore always 
use ether. After the patient is under ether and in position 
she should have one final scrubbing up with soap and water 
by the nurse. Before the nurse scrubs the patient up she 
should wash her own hands thoroughly. Care must be taken 
not to use a great amount of water in the preparation. She 
should use the same care that was described in the prepara- 
tion for a normal delivery. The soap and water is washed 
off either with sterile water or corrosive sublimate solution 
1-3000 and the preparation finished with 70% alcohol. The 
objection to the use of alcohol is the expense, and to corro- 
sive, that in some patients it causes a dermatitis which 
is most annoying. After the patient is in position and pre- 
pared, the sterile pad which comes in the obstetrical package 
is placed beneath the patient's buttocks. If there is no pad 
a sterile towel is used instead. Over the pad is placed a 
towel and this goes underneath the buttocks and is held in 
place by the patient's weight. Towels on the flexed legs add 
to the completeness of the operating outfit but there is no 
real necessity for them for if a physician cannot operate with- 
out touching the adjacent legs he ought not to be allowed to 
operate at all. I do not have a towel put upon the abdomen 
because I like to be able to see the nurse's hand as she follows 
down the uterus. The next step is to catheterize the patient. 



1 62 CASE HISTORIES IN OBSTETRICS. 

A soft rubber catheter only should be used before delivery 
and this must be thoroughly boiled. The meatus is first 
wiped off with 1-3000 corrosive and then the catheter placed 
directly into the meatus touching nothing but the meatus. 
Many times in pushing the catheter in a little way it will 
meet an obstruction. Never try to force a catheter. With 
a finger in the vagina along the course of the urethra gently 
guide the tip between the presenting part and the symphysis. 
If the presenting part is too close push it up a little way and 
then gently push the catheter in further. Absolutely no 
force must be used and unless you can catheterize without 
force it is better to let the patient go without catheterization, 
especially when the head is so low. When the urine comes, 
leave the catheter as it is and after it has stopped flowing pull 
the catheter out a little way and very often more urine will 
come away. Many times it will be advisable to ask the 
nurse to press down over the bladder region to help empty 
the bladder. When all the urine has ceased running pinch 
the catheter and gently remove it. 

The next step is the dilatation of the perineum. If the 
head is very low, directly on the perineum, you will be able 
to do nothing more than to insert the fingers slowly into the 
vagina and gradually stretch the perineum a little more. If 
it is so tight that you cannot get in with any degree of safety 
without rupturing the perineum, the dilatation takes place 
after the forceps are on and the extraction is beginning. If 
this latter can be avoided, much better results will be obtained 
if complete dilatation of the perineum is obtained before the 
head is brought over it. A method that has been very suc- 
cessful in my hands is as follows: two fingers of each hand, 
the index and the middle fingers, are inserted slowly and 
carefully into the vagina, the pulp of the fingers downward 
on the perineal muscles. The dorsal surfaces of the fingers 
are brought together in the median line ; the fingers are then 
flexed from the metacarpo-phalangeal joints. This flexion 
gives pressure downwards and outwards on the levator ani 
muscles and gradually the perineum is stretched. This must 
be accomplished without tearing. If the head is very low 
the whole hand cannot be inserted unless the head is pushed 



FORCEPS. 163 

Up. If the head Is very firmly wedged down It generally Is 
not advisable to force It back, but to complete the dilatation 
slowly by means of the head alone. Gradually and slowly 
the entire hand Is Inserted. After getting In the entire hand 
the fist Is clenched and the posterior surface of the wrist held 
at the symphysis and the fist Is then flexed slowly out of the 
vagina. In this way the perineum Is put on the stretch In a 
manner which approximates the way the head stretches It. 
Several times the perineum is thoroughly stretched In this 
manner until the fist can be readily brought out over the 
perineum. Objection has been made to stretching the peri- 
neum in this way, some physicians claiming that the process 
tears the perineum. Unquestionably at times it may, but 
in those cases where a tear occurs In the dilating, provided 
the dilating is done without haste, undoubtedly the perineum 
would be torn if It were not stretched. I am confident that 
the tears after a thorough dilatation of the perineum are very 
much less than In cases where the perineum Is not stretched. 
Another objection Is made that it takes time to dilate the 
perineum completely. It does take time, but It takes less 
time to dilate a perineum thoroughly and completely than it 
does to sew up a bad tear afterwards. The skin is not only 
thoroughly stretched, but the muscles as far back In the outlet 
as the fingers can reach are also thoroughly dilated. After 
the dilatation of the perineum is completed and before the 
forceps are applied the os uteri must be examined. It Is 
obvious In many cases that forceps deliveries are undertaken 
before the os Is fully dilated. If this Is done the danger to 
the patient is much increased because the liability to severe 
cervical tears is great. If the os uteri Is not fully dilated It 
must be dilated up carefully and as fully as possible with the 
hand. (Cases 18, 20, 21, 44, 51.) After full dilatation is 
obtained draw the closed fist through the cervix at least three 
times so that there will be no resistance or at least as little as 
is possible from the cervix. Some operators apply forceps 
through a cervix which is not fully dilated. Unquestionably 
it can be done. Forceps can be put on as soon as the cervix is 
dilated enough to admit the passage of the blade. If forceps 
are put on in this way, then as traction is made downwards, 



1 64 CASE HISTORIES IN OBSTETRICS. 

pressure upwards on the anterior and posterior lips of the 
cervix is made with the fingers of the hand that does not hold 
the forceps. If the anterior and posterior lips are not pushed 
back there is too much pulling downwards on the uterine 
supports and in my opinion more serious tears are apt to 
occur than when the cervix is dilated at first and before the 
forceps are put on. Case i8 was dilated in this manner and 
no untoward symptoms arose when she was up and about. 
The beginner, however, should not attempt a forceps delivery 
until the os is fully dilated. If he thinks delivery is indicated 
he had much better send for help than to attempt it himself. 

The perineum and cervix fully dilated, the next step is the 
rupture of the membranes if they have not already ruptured. 
Rupture them either with the finger or with a rat-tooth for- 
ceps. As the liquor comes away note whether it is clear or 
meconium stained or whether meconium unmixed with liquor 
appears. If it is the latter it is presumptive evidence that 
the baby is in serious danger and a speedy delivery is indi- 
cated. If the liquor is meconium stained it is suggestive of 
past danger, provided the fetal heart is now regular in rate 
and rhythm. (Case i6.) 

Successful operative obstetrics cannot be done unless the 
position of the child in utero is accurately determined. In 
determining the position of the child, palpation of the abdo- 
men before the question of operative procedure has come 
up, is of marked help, but palpation alone must never be 
relied upon. The simplest of all forceps deliveries is where 
the head is on the perineum, the sagittal suture is in the 
antero-posterior diameter of the pelvis and the anterior 
fontanelle is not felt. (Case 15.) In such cases as this where 
the head is so low that an ear cannot be felt, one must rely 
entirely upon the relation of the f ontanelles and sutures to the 
mother^s pelvis. The posterior fontanelle is made, as everybody 
who is attempting to do obstetrics must know, by the junction 
of two sutures, the lambdoid and the sagittal. It is three 
cornered and small. The anterior fontanelle is diamond 
shaped, larger and is made by the junction of the coronal, 
frontal and sagittal sutures. Joining the two fontanelles 
is the sagittal suture and it is the relation of this sagittal 



FORCEPS. 165 

suture and the fontanelles to the antero-posterior diameter 
of the mother's pelvis that tells one whether the occiput is 
fully or only partially rotated to the arch of the symphysis. 
Even knowing the fact that the anterior fontanelle is diamond 
shaped in a hard labor where there is much overlapping of 
the sutures, it is very difficult, almost impossible at times, to 
settle which fontanelle one has to deal with. For this reason 
other landmarks must be sought. The usual landmark 
sought is the ear. The examining finger sweeps over the 
ear and you determine whether the auricle points anteriorly 
or posteriorly by getting the finger behind it and trying to 
fold the ear over on itself. 

Case 15 shows the simplest forceps delivery that can take 
place. The occiput is fully rotated, head on the perineum. 
The cervix is not felt. The forceps are held in front of the 
vulva as they are to be applied to the child's head. The left 
blade, the one with the lock, is then taken and held in a verti- 
cal position with the tip downwards so that the cephalic 
curve of the forceps is parallel to the contour of the head of 
the baby. Whether the handle is held as a scalpel, or 
whether it is held with the whole hand, to me is immaterial. 
The fundamental point, more important than how it is held, 
is that in the application no force must be used. There are 
three points in the pelvis, with a low head, where the forceps 
can be applied most easily. Either directly backwards to- 
wards the hollow of the sacrum or towards the left or the 
right sacro-iliac synchondrosis. If these three places are 
remembered and the application of the forceps always begun 
in one of these three places, any part of the head in any posi- 
tion can be reached from one or the other of these three 
places. The blade is then inserted along the gloved fingers 
of the right hand so that the danger of carrying any infection 
from the vagina is reduced to the minimum. In passing it 
should be stated that the blade must never touch the vulva 
before it is put inside the vagina. The handle is then dropped 
downwards, remembering always that the blade has the 
pelvic as well as the cephalic curve. Judgment and experi- 
ence alone will tell whether the blade is in position. The 
left blade in position, placed by the left hand, the right blade 



1 66 CASE HISTORIES IN OBSTETRICS. 

is then taken in the right hand, held in a corresponding man- 
ner and is put in the vagina towards the right sacro-iHac 
synchondrosis and swung up into place opposite the first 
blade. The first blade is placed always where your best 
judgment tells you you want it. That blade, placed and 
held steady at one point, is always used as the guiding blade 
and the second blade is put on to lie opposite. If the first 
blade is rightly placed, the second must be approximately 
right or otherwise the blades would not lock. The blades 
applied, the fetal heart should then be listened to in every 
forceps delivery. The importance of this was seen in Case 
20 where the cord was down beside the head and it would 
have been a very easy matter to pinch the cord by the for- 
ceps, an accident which is not very uncommon, though 
sometimes not admitted as the cause of the death of the 
baby. In Case 15 there was no question whether the for- 
ceps were put on inside or outside of the cervix as the cervix 
could not be felt. In all cases the forceps must be put on 
inside the cervix. The danger is so obvious, should the for- 
ceps be applied outside the cervix, that no comment is neces- 
sary. Case 18 shows the care that is to be taken in avoiding 
the cervix when the os uteri has not retracted beyond the 
head. 

The application of both forceps blades with one and the 
same hand is many times readily done, but the beginner, until 
he is very familiar with the application of the forceps with 
two hands, should not attempt it. The technique used in 
applying the second blade is totally different from that where 
two hands are used. The beginner must master the usual 
technique of using two hands and when this is accomplished 
the technique of using the one hand for the application of both 
blades he can readily work out himself. 

Forceps applied, the first traction should always be tenta- 
tive to see whether or not the forceps slip. To determine 
whether any slipping of the forceps takes place, put the index 
finger of one hand on the occiput and note the distance be- 
tween the occiput and the lock of the forceps. If this dis- 
tance increases then the forceps are slipping and must be 
reapplied. Properly applied the forceps slip but very little. 



FORCEPS. 167 

The first traction is practically always downward and out- 
ward until the occipital protuberance is sunk beneath the 
arch. In Case 21 much traction downward was necessary 
before the occiput was brought low enough so that extension 
could take place. If the head is extended too soon the occi- 
put may exert such pressure on the arch of the symphysis 
that the joint will rupture. 

Traction and compression must be intermittent, approach- 
ing as near as possible the action of the uterus. All traction, 
every motion, in a forceps delivery must be slow and deliber- 
ate, never a sudden motion. In Case 22 traction was applied 
and a sudden jump of the head by the promontory took place. 
Fortunately no serious damage was done to the maternal 
soft parts, but such sudden movements are wrong in elective 
forceps deliveries. 

As the head distends the perineum, press, with the finger, 
as described in normal deliveries, on the baby's scalp to 
determine the condition of the baby. If the circulation is 
good go very slowly with the extraction. Let the head 
recede, take all pressure off the perineum and allow the cir- 
culation in the perineum to be sufficient. If the circulation 
of the scalp be poor, hurry the extraction even to the degree 
of obtaining severe lacerations. The more skillful the opera- 
tor, the better judgment he shows in operating, the slower 
will be his operative deliveries. Serious lacerations usually 
come from hurried bungling operations. 

Whether the operator removes the forceps before the head 
is delivered is usually a personal matter. The beginner will 
many times take the forceps off only to find the head recede 
and a re-application becomes necessary. With a tight peri- 
neum if the forceps are removed you do gain a little more 
room. Before you remove the forceps take a sterile towel on 
your left hand and press upwards behind the anus. If by 
this step you see you can deliver the head, swing the thumb 
of the left hand up to the head and hold it at the point to 
which it has come. Now take off the right blade, revers- 
ing the motions by which it was applied. The same is then 
done with the left blade. If the blades come off readily, well 
and good, but do not pull and use force. Never remove the 



1 68 CASE HISTORIES IN OBSTETRICS. 

blades unless you have your hand against the head; for a 
contraction of the uterus might come and force the head 
quickly over the perineum and a serious laceration occur. 
The head delivered, the same steps follow as in a normal 
delivery. 

The higher the head in the pelvis the more dangerous may 
be the delivery. The reader is referred to the several text 
books for diagrams of the different planes of the pelvic cavity 
and explanation of the course the head takes in its passage 
through these planes. It is beyond the scope of this book 
to go into these problems. A full understanding, however, 
of these planes and of the mechanism of labor must be had 
for successful operative obstetrics. 

Case 17 shows that it is possible to deliver cases where the 
rotation of the occiput is but half completed with but one 
application of forceps. Had the forceps in this case been 
applied to the sides of the pelvis irrespective of the position 
of the head, as is advised so often, the difficulty in the de- 
livery would have doubtless been much increased. If the 
rotation of the occiput is completed to the transverse diam- 
eter of the pelvis or more, the delivery takes place with one 
application. If there is no rotation forward, or not to the 
transverse diameter, the double application is best as is seen 
in Case 19. Here the position was occiput left posterior, 
unrotated, the head was high, practically floating and a double 
application was necessary. With the second application the 
head was brought down into the pelvis and rotated to the 
arch. The forceps, therefore, became completely reversed. 
They were then removed and were reapplied to the fully 
rotated head. Always, before you begin the second appli- 
cation, examine to make certain that the occiput has not 
slipped back into its first position. 

With unrotated posterior positions, it is always best, if pos- 
sible, to rotate manually the occiput anteriorly before any 
attempt is made to apply the forceps. In left positions the 
right hand is used to rotate the occiput forward and in right 
positions the left hand. In right positions the right blade 
should be applied first for when it is applied it can many 
times be so held that it will prevent the occiput from slipping 



FORCEPS. 169 

back. (Case 21.) The same holds true in left positions 
where the left blade is first applied. When the right blade 
is applied first it comes to lie below the left one and in order 
to lock the blades it must be raised up and rotated about the 
left blade which then is slightly depressed. 

In all cases where the biparietal diameter of the child*s 
head is not well through the inlet of the pelvis, pressure on 
the head through the abdomen by the assistant should be 
given in order to steady the head as the application of the 
forceps takes place. (Cases 19, 21.) The head is grasped 
by the assistant with his thumb and forefinger. Too great 
pressure must not be used for this increases the difficulty of 
applying the blades. The assistant, as the blades are applied, 
readily feels them come up into place. When locked he re- 
moves all pressure and then listens to the fetal heart. I 
speak of an assistant as if it always were possible to have one 
with you. I realize full well the difficulty in country places 
of obtaining anyone to help outside the immediate family, 
but I nevertheless feel that the risk physicians take is often- 
times unnecessarily great. In these days of farmers' tele- 
phones and automobiles, with a little planning, help may be 
obtained if it really is wanted much oftener than it is sought. 
Oftentimes personal animosities are the reasons for not seek- 
ing outside help but such trivial reasons should be put aside 
in serious work. 

The object of all traction-rods on forceps is to obtain trac- 
tion as nearly at right angles as is possible to the plane in 
which the head lies. Therefore, the higher the head is in the 
pelvis the further back towards the perineum is the traction 
needed. Experience alone will tell how to exert this traction 
and when to change the direction of it. Intelligent watching 
of a skillful operator, who will explain the various steps as he 
operates, is an excellent method of learning some of the 
points. Manikin work is of great aid but experience on the 
living subject must be obtained before any one can be skillful. 

High forceps work, that is, where the biparietal diameter 
of the fetal head is not through the brim of the pelvis is un- 
reservedly condemned by certain obstetricians. I have never 
seen any reason for such a sweeping condemnation. High 



170 CASE HISTORIES IN OBSTETRICS. 

forceps where there is no disproportion between the fetal head 
and the pelvis is an excellent operation in careful hands and 
never will be given up. Cases 19, 20 and 21 were all high 
forceps applications but there was no disproportion present. 
All made excellent recoveries, the babies all are now living 
and well, and the mothers show no disabilities. Forceps 
deliveries when there is disproportion are dangerous and 
should not be done. Case 22 is an excellent example of a 
forceps delivery of necessity, with bad results, though even 
here the result might have been worse. This patient refused 
to allow any '* cutting" operation. Version in a tight uterus, 
tightly contracted about the baby was contra-indicated and 
there was nothing left but forceps or a destructive operation. 
I elected to attempt forceps with the result above described. 
It is from such cases as these that the high forceps operation 
receives its bad name and rightly so, but even in these cases 
it is not an unjustifiable operation. The fault lies not in the 
operation but in the time when the operation is by necessity 
done. 

Case 20 should have been managed differently in the early 
part of the case. Insertion of a Voorhees bag when labor was 
found to be inefficient would have materially shortened this 
labor. The patient would in all probability have been in 
much better condition after such treatment than she was 
after the operative delivery to which she was subjected. 

There are many indications for forceps deliveries as is seen 
from the above cases. They can be classified as in the in- 
terests of the mother, or of the child, or of both. 

Lack of progress is the usual cause for delivery. The 
more skillful the operator the sooner is he justified in operat- 
ing. If a physician by operative deliveries obtains severe 
tears, sepsis or injuries to the baby, he must study his cases 
more carefully and see if he is justified in operating so quickly. 
It is a well established fact that the greater part of gyneco- 
logical operating is due to bad obstetrics. It is a terrible 
arraignment of past and present obstetrics. The beginner, 
if the patient is in the second stage two hours without any 
progress, as shown by the descent of the head, may consider 
operating. If progress is made, the beginner should let nature 



FORCEPS. 171 

take Its course. The teaching of obstetrics in this country 
should be so improved that all physicians on graduating will 
be capable of doing simple low forceps work without mor- 
bidity. 

Reference to the above histories shows typical reasons for 
interfering. There is in all a similarity. One might ask in 
Case 16 why interference was not undertaken earlier because 
of the Irregular fetal heart. I felt that I might have to in- 
terfere at any moment and for that reason sent for an assist- 
ant early and had everything ready for a quick delivery, but 
I realized the cervix, which was not fully dilated and thick 
at the first examination, might make the delivery very diffi- 
cult. I therefore waited hoping for an easier operative de- 
livery and that the fetal heart would straighten out. For- 
tunately it did so, but had it not, preparations were complete 
for interference. 

Watchfulness is of prime importance in obstetrics. Had 
Case 20 been watched more intelligently the physician in 
charge would never have diagnosed a placenta praevia for an 
edematous anterior lip of the cervix. Be prepared to oper- 
ate any moment; operate only when the indication is real, 
not fanciful. Realize that many women of the so-called 
better class will not stand a long hard labor with Impunity 
and if you are not competent to interfere early in these cases 
send for help early. 

The question may be raised here why pitultrin or hypo- 
physln was not used In several of these cases where the powers 
of expulsion were not quite sufficient to accomplish delivery. 
In cases where there is no obstruction to delivery, and where 
the soft parts are easily dilatable, it is permissible to use one 
of these preparations. Both of these preparations cause 
hard uterine contractions, but they may be of the long-con- 
tinued tetanic type which is dangerous not alone to the baby 
but also to the mother. When there Is disproportion present 
between the pelvis and the fetus the danger is very great. 
If there Is no disproportion, but the soft parts are rigid and 
not dilated danger again Is present. Severe lacerations, 
ruptured uteri, asphyxia of the baby may be looked for when 
these latter conditions are present. Few obstetricians use 



172 CASE HISTORIES IN OBSTETRICS. 

these preparations to any great extent. I am constantly 
finding general practitioners using them to hurry the de- 
livery. They admit the tumultuous type of labor these prepa- 
rations cause, they admit the lacerations have been severe 
in many cases, but as long as their time is conserved and they 
have no serious accident with the mother they apparently 
do not care. Pituitrin or hypophysin unquestionably will 
shorten labor, but except in the type of case in which I have 
already agreed to their use, they are dangerous and in the 
hands of the unscrupulous will cause much suffering. 



SECTION V. 
BREECH DELIVERY. 

Case 23. MuLTiPAROUs Breech Delivery. Patient is 
seen for the first time November 20. She says she is five 
months advanced in her fourth pregnancy. The first day of 
her last menstruation was June 19; dehvery is therefore due 
from the twenty- third to the twenty-ninth of March. Her 
first pregnancy was terminated by a forceps delivery. In 
her second and third labors she delivered herself. The 
children weighed between eight and eight and a half pounds. 
She is in excellent physical condition. Present pregnancy 
has progressed normally. Blood pressure is no and urine 
examination is normal. 

March 14. Up to the present time there is nothing of 
interest to note. To-day she is seen and says that for the last 
ten days she has noticed that she has indefinite sensations of 
discomfort low down in the region of the bladder accompanied 
by a very frequent desire to pass urine. She says she "feels 
as if there was motion in the vagina." When this ''motion" 
ceases the desire to pass urine disappears. Urine analysis 
was negative. 

Palpation : — Firm smooth resistance is on the right ; 
small parts felt on the left. At the fundus is a definite hard 
round mass which is readily outlined. Ballotment is readily 
obtained. There is no presenting part engaging in the pelvis. 
Fetal heart is best heard in the right lower quadrant, 120 to 
the minute. 

Diagnosis: Breech presentation; the history suggests a 
footling. 

The remainder of this pregnancy is not remarkable except 
for the discomfort of the "motion" in the vagina, which at 
times necessitated the patient voiding urine occasionally as 
often as every fifteen minutes for one or two hours. Blood 
pressure has at no time been over 120 mm. of Hg. 

173 



174 CASE HISTORIES IN OBSTETRICS. 

March 25. At 9:30 p.m. patient began to have a few in- 
definite pains at irregular intervals. At ten the nurse reports 
that the pains began coming every five minutes and were of 
forty-five seconds duration. I went to the patient at once. 
Palpation confirmed the previous note. Fetal heart 130, 
regular, heard only in the right lower quadrant. At eleven, 
the membranes ruptured. Fetal heart listened to at once 
and found the same. Vaginal examination made and the 
OS found fully dilatable and very soft. Anterior lip of the 
cervix found low in the vagina and there is a feeling of fullness 
between the anterior lip and the symphysis. At the os small 
parts are felt presenting. It was suggested to the patient 
that she try to void her urine. She did so at once and voided 
ten ounces of urine. 

Pains now came every three minutes and lasted one minute. 
Fetal heart was listened to every fifteen minutes and remained 
regular at 130. At five minutes of twelve a foot appeared 
at the vulva. Up to this time the patient had been lying 
on her left side. She now was turned on her back across the 
bed with her buttocks on the edge and her feet resting in a 
chair. Obstetrical ether was given with each pain which 
came every two minutes and lasted a minute. A second foot 
at once appeared. Ether was forced and patient held in 
lithotomy position and fundal pressure by the assistant 
accompanied the delivery of the body. The baby's legs were 
simply supported and on the next pain the buttocks appeared 
and the body followed. The cord was found pulsating. Both 
arms were found flexed on the chest and were readily drawn 
down. The body came down in the right oblique diameter 
and was held in this diameter. Patient was now fully under 
ether and with the aid of suprapubic pressure the head was 
at once born. The baby cried immediately. Ether was now 
stopped. There was a very slight tear of the perineum. 
The cord was clamped and cut. Perineum was repaired with 
one silk worm-gut suture. Placenta came away intact with all 
the membranes on the third pain. Uterus remained well con- 
tracted and was held for twenty minutes. The baby weighed 
eight pounds and two ounces. The puerperium was absolutely 
normal and the patient got up on the twenty-first day. 



BREECH DELIVERY. 175 

Case 24. Primiparous Breech Delivery. The patient 
is a primigravida, twenty- three years old, five months ad- 
vanced in her pregnancy. There was nothing of interest to 
note as her pregnancy advanced. Blood pressure was never 
over 120 mm. of Hg. All urinary examinations were normal. 

Palpation at the beginning of the ninth month showed a 
small baby, head presenting, in a left position. Fetal heart 
heard in the left lower quadrant. Measurement of her pelvis 
gave crests 26 cm., spines 25 cm., external conjugate 20 cm. 
Two weeks later she is again seen and volunteers the informa- 
tion that three days before there was a great deal of motion 
for a time and that she thought the baby had ''turned over." 
Palpation now showed small parts on the left, marked resist- 
ance on the right and head at the fundus. Fetal heart is 
not heard, fetal motion is seen. Presenting part is free above 
the brim of the pelvis. 

Vaginal Examination : — Cervix soft, partially taken up 
and the external os admits one finger. Presenting part can 
just be reached. Contour of the true pelvis is normal. Bi- 
ischial diameter is 10 cm. with Williams pelvimeter. Small- 
boned woman. My note at that examination says "at the 
present time the baby does not weigh more than seven 
pounds and if delivery takes place when due there seems 
to be no reason why the baby will not come through without 
difficulty." 

Ten days later I received a telephone message at 2 150 a.m. 
saying that the patient had just been awakened by the waters 
coming away. I went to her at once and when I arrived at 
4:30 A.M. she was having definite uterine contractions at 
fifteen-minute intervals lasting but thirty seconds. Fetal 
heart at once listened to and was heard at the umbilicus 120 
to the minute, loud and regular. Palpation gave the same 
findings as previously. She was prepared in the usual man- 
ner (see page 107) and then examined. Cervix was taken 
up, OS dilated one inch, frank breech readily reached by 
examining fingers, no cord felt. At six o'clock pains were 
coming regularly every eight minutes lasting from 45 seconds 
to a minute and a half. Uterus relaxed well between pains. 
The patient was kept in bed because liquor came away with 



176 CASE HISTORIES IN OBSTETRICS. 

each pain. Patient's pulse was 70. Fetal heart was now 
listened to every half hour and it remained regular at 120. 
By half past ten the pains were coming every two minutes 
and lasting one minute. Vaginal examination now showed 
the breech in the mid-pelvis, posterior lip of the cervix not 
felt, anterior lip thin but readily felt. The pains became 
more severe and the patient began to bear down with each 
pain. At eleven she began to complain that she had stood 
about all she could and wanted ether. Uterus was relaxing 
well between pains; it was not tender on palpation. Fetal 
heart stayed regular and was listened to every fifteen minutes. 
She was now given obstetrical ether and obtained much relief. 
The pains continued to come regularly and with each pain 
she worked well. During a pain the fetal heart ran up to 
140 but at once dropped back to 120 and remained regular. 
Patient's pulse during pains would rise to 100 but then drop 
to 80. 

With obstetrical ether she was carried along, at no time 
losing consciousness, until quarter past one when the breech 
appeared at the vulva. Perineum now bulged with each 
pain. No variation in the fetal heart. For the next hour 
she made but very slight progress. Fetal heart now began 
to be 140 and occasionally during a pain it ran up to 160. 
Because of the lack of progress and the slight rise in the fetal 
heart I decided upon delivery. 

Patient now was etherized by an assistant whom I had sent 
for six hours before. She took ether badly, vomiting several 
times, but each time she vomited she pushed the breech 
further down onto the perineum and stretched it up con- 
siderably. She was placed in moderate lithotomy position 
and when under full anesthesia prepared in the usual manner. 
The perineum was thoroughly dilated. Bladder catheterized. 
Position S. D. P. Index finger of left hand hooked around 
the anterior groin and with traction downward the anterior 
buttock was brought into view. Index finger of right hand 
readily reached the posterior groin and with downward 
traction and lateral flexion the buttocks were delivered. It 
was then seen that the legs were fully extended on the baby's 
abdomen. Traction downward was continued and when 



BREECH DELIVERY. I77 

the right knee appeared flexion freed the right foot. The 
left foot was then freed in a similar manner without difficulty. 
The baby^s back was directed slightly backward to the 
patient's right side. Both hands now seized the baby's 
pelvis with the thumbs on the sacrum. The baby was rotated 
slightly to the right so that the shoulders came down in the 
right oblique diameter and they were kept in this diameter. 
Traction at first downward and then slowly and gently 
upward brought the spines of the scapulae into view. The 
legs were then lifted upward and outwards to the patient's 
left by my right hand and with the left hand the perineal 
arm was readily delivered. Grasping the legs with my left 
hand and drawing them down and outward towards the 
patient's right, with my right hand over the anterior shoulder 
I swept down the right arm, the anterior, which was extended, 
over the face and the perineum. Care was taken not to let 
the baby's abdomen rotate anteriorly. The baby was then 
placed on my right forearm with the legs astride my arm. 
With two fingers of my left hand on either side of the child's 
neck, palm downwards, I made traction downward. At the 
same time the etherizer gave me intelligent suprapubic 
pressure. The chin at once appeared at the perineum and 
the body was lifted upwards and the head was born without 
any difficulty. After the birth of the child the cord was 
found pulsating and in a few seconds the baby gasped and 
soon cried lustily. The cord was tied and cut. There was 
no bleeding. Examination of the perineum showed a median 
perineal tear only about half an inch deep but extending skin 
deep down to the sphincter muscle but in no way involving 
the muscle itself. One chromic catgut suture placed deep 
and tied brought the tear well together. Three silkworm-gut 
sutures were then placed and brought the skin into excellent 
approximation. Finally a chromic catgut stitch was placed 
just above the sphincter to hold the skin in absolute approxi- 
mation. Before the silkworm-gut sutures were tied the 
placenta was delivered and examination showed it to be 
intact with all the membranes. The baby weighed six 
pounds and fourteen ounces. 

The uterus acted well and there was no bleeding. Pulse 



178 CASE HISTORIES IN OBSTETRICS. 

1 10 and good quality. At 5:30 the patient began to have a 
severe chill, which lasted until controlled by morphia, gr. 
1/6, for ten minutes. Pulse at the end of this chill was 120, 
volume distinctly poorer than before. Uterus stayed hard 
and no bleeding present. At 6:30 she was in excellent con- 
dition, breathing regularly, of good color, pulse no, regular 
and of good volume. Temperature 100°. I left her at seven 
o'clock, both she and the baby in excellent condition. 

First day. Temperature this morning 99°, pulse 90. Slept 
but little last night. Voided early this morning. Uterus 
well contracted and not tender. Lochia normal. Stitches 
look well. No edema present. 

Second day. Morning temperature 98°. Pulse 72. Even- 
ing temperature 99.4°, pulse 82. 

Third day. Morning temperature 97.8°, pulse 72. Patient 
is in excellent condition. Uterus three finger breadths below 
the umbilicus, hard and not tender. Lochia normal. Except 
for slight hoarseness which she has, is very comfortable. 
There is no sign of any milk in the breasts. Bowels moved 
to-day by castor oil given early this morning. Evening 
temperature 98.6°, pulse 74. 

Fourth day. Morning temperature 98.8°, pulse 84. Last 
night she was reported by the nurse as having a hacking, 
irritating cough for which she was given codeia sulphate, 
gr. 1/2 intramuscularly, with marked relief. Patient can 
speak only in a whisper. Examination of throat shows 
markedly reddened pharynx. Examination of abdomen nega- 
tive. Examination of the lungs shows that a definite bron- 
chitis is present. 

From now until the tenth day the patient ran an irregular 
temperature varying from 99° to 101°, the pulse running 
from 70 to 100. The bronchitis gradually cleared up. At 
no time did the patient appear sick. The uterus involuted 
well; there never was any abdominal tenderness and the 
lochia was at all times normal in character. 

From the tenth day she made a steady improvement. 
Pulse and temperature came down by lysis and on the tenth 
day became normal. The stitches were removed on the 
tenth day and the perineum apparently was well healed, 



BREECH DELIVERY. 179 

except just above the anus where there is a slight separation 
of the skin and there is a small cavity present with a dirty 
base. A very small sterile gauze wick was packed into this 
cavity morning and night by the nurse and in four days it 
was solidly healed. 

Convalescence was now uninterrupted and she got up on 
the twenty-first day. The final examination was made in 
the sixth week. Lungs were found to be clear. Abdomen 
negative. Excellent result on the perineum, slight bilateral 
tear of the cervix, lateral fornices equal but are shallow. 
Uterus normal in size and position, freely movable, no tender- 
ness. There is no vaginal discharge. Breasts are normal. 
Baby's umbilicus is healed. Movements are normal. 



l80 CASE HISTORIES IN OBSTETRICS. 

Case 25. Breech Extraction. Dry Uterus. Con- 
traction Ring. Patient is seen in consultation Sunday, 
September 24th, at eight in the morning. The following his- 
tory is obtained from the attending physician : — The patient 
is a primipara who has been in labor some thirty hours with 
a breech presenting. Rupture of the membranes had taken 
place coincidentally with the beginning of labor, early Satur- 
day morning. All day Saturday the patient had a slow, 
nagging labor. Dilatation was accomplished very slowly, 
accompanied by a leakage of the amniotic fluid. She had 
become fully dilated about two a.m. Sunday morning and 
after a hard second stage the physician decided to deliver her 
at about six a.m. She was etherized, but all attempts he 
made to accomplish delivery were futile. He said the uterus 
was contracted so tightly about the child that it was impossible 
for him to get up far enough into the uterus to reach a foot 
and with a finger in the groin he was unable to deliver the 
baby. He ceased his efforts at a little after seven and tele- 
phoned for me to come out to help him. 

At eight o'clock the condition I found was as follows: — 

A large, heavy woman partially under ether. Pulse 120, 
of good volume and regular. The uterus was tight and ten- 
der on palpation especially tender just above the pubes. The 
fetal heart was not listened to. No further examination was 
made. Immediate delivery was indicated. 

While making the necessary preparations I told the hus- 
band that the chance for a live baby was only of the remotest 
possibility and that the patient's condition was grave. As 
soon as possible she was again put well under ether, placed 
in the dorsal position and the vulva carefully cleaned up with 
70% alcohol. Examination showed that the perineum had 
been torn to the sphincter, the circular fibers of which were 
readily seen. A frank breech was presenting in S. D. A. 
position at the pelvic inlet. The os was fully dilated. Just 
beyond the os the examining hand came to a tight ring which 
was felt completely encircling the breech. With moderate 
pressure I attempted to push my hand by this ring but with 
the force I felt justified in using I could not. The uterus was 
so firmly contracted that there was no possibility of pushing 



BREECH DELIVERY. l8l 

the whole breech upward to gain room. I could just reach 
the anterior groin but with the traction I could get by means 
of a finger there was no gain. The posterior groin I could 
not reach. I then placed in the anterior groin a blunt hook. 
With strong, steady traction downward the anterior thigh 
was brought to the vulva. The blunt hook was removed 
and with a finger in the anterior groin and one in the posterior, 
traction downward was again begun but without success. 
The blunt hook was again placed in the anterior groin. 
Strong traction brought the breech still further down and the 
femur then snapped. With a finger in each groin the but- 
tocks were then delivered. Both legs were fully extended 
on the baby's abdomen. When the popliteal spaces appeared 
the knees were flexed, first the anterior one and then the 
posterior one and the feet were readily delivered. Neither 
arm was extended and first the perineal arm and then the 
anterior arm was readily delivered. Considerable traction 
was necessary to deliver the head but on the second attempt 
with the help of excellent suprapubic pressure it was accom- 
plished. 

The baby was pale and limp and was given the attending 
physician to resuscitate. It breathed soon but did not cry. 

Patient's pulse was reported as 120 and of poor quality. 
There was not time to make a careful repair of the perineum. 
I quickly placed and tied two No. 2 chromic catgut sutures 
in the deep perineum which brought the internal tear fairly 
well together. I then placed rapidly three silkworm-gut 
sutures. The placenta was then delivered intact with all 
the membranes. The silkworm-gut sutures were then tied. 
No douche was given. Sterile pad placed over the vulva 
and the patient turned about in the bed and surrounded by 
hot-water bottles. The fundus was carefully held for one 
hour. The pulse slowly but steadily improved in character, 
the rate remaining 120. She made an excellent recovery 
from ether with no vomiting. 

The baby continued to breathe regularly but did not cry. 
Its respirations were very shallow and rapid, and it was limp 
and pallid. It was in no condition to be handled and as the 
fragments of the femur were readily held in apposition by 



1 82 CASE HISTORIES IN OBSTETRICS. 

flexing the thigh on the abdomen the leg was thus held in 
place by a cotton roller bandage. The leg and body were first 
oiled and then covered with absorbent cotton. It was very 
evident that the baby would not long survive the difficult 
delivery and about noon it died. 

On September 29th the attending physician telephoned 
that the patient was making an excellent convalescence. On 
the night of the delivery the temperature rose to 102.6° and 
the pulse stayed 120. The next morning the temperature 
dropped to 99° and the highest it reached thereafter was on 
the second day when it was 100.2°, with a pulse of 95. Since 
then until now the temperature has been normal and the 
pulse varied from 80-90. Except for a slight amount of 
edema the perineum is looking very well. 

October 20th the physician telephones the patient has 
made an uninterrupted recovery. The perineum has healed 
well. As yet the physician has not examined her vaginally. 
She is up and about the house with no discomfort in the 
perineum and without any discharge. 



BREECH DELIVERY. 1 83 

Case 26. Primiparous Breech Extraction. January 
25. A telephone message from the attending physician at 
eleven-thirty in the evening saying that he had a "primipara 
in labor, a breech presenting, that the patient had become 
fully dilated at eight and was now making no progress and 
that he thought she ought to be delivered." 

I saw the patient at one a.m. January 26th and obtained 
the following story : — Her pregnancy had been normal with 
the exception that from the seventh to eighth month her 
legs and lower abdomen had become very edematous. The 
urine at this time was negative and nothing wrong was found 
in the heart. The only explanation that the physician could 
offer for this condition was the fact that she had worn her 
corsets extraordinarily tight for a woman so far advanced in 
pregnancy and when he forbade their use entirely the con- 
dition gradually cleared up. The patient started in labor 
at eight o'clock the morning of the twenty-fifth with contrac- 
tions coming slowly and without force. At this time there 
was a slight show. At one p.m. the pains began coming every 
five minutes and lasted from one and a half to two minutes. 
From then until ten p.m. the pains continued coming at this 
rate, and there continued to be a slight show. Vaginal 
examination by the attending physician at this time showed 
the breech still high. The posterior lip of the cervix could 
not be reached but the anterior was readily felt. At eleven 
o'clock the pains began to die out, coming only once in ten 
minutes and lasting but from one-half to three-quarters of 
a minute. 

When I saw her at one a.m. the pains were coming the same 
as last noted. The uterus contracted well, relaxed only 
fairly well between pains and on palpation was markedly 
tender, especially below the level of the umbilicus. No 
retraction ring was palpated. Head was readily palpated 
at the fundus. Fetal heart was definitely heard an inch to 
the left and above the umbilicus, 150 to the minute and 
slightly irregular. Patient's general condition is satisfactory, 
pulse of good volume, 90 to the minute. 

Vaginal Examination : — Introitus edematous, pelvic 
walls soft and apparently edematous. Anterior lip of the 



1 84 CASE HISTORIES IN OBSTETRICS. 

cervix is caught between the descending breech and the sym- 
physis and is very edematous. Without ether it could not 
be pushed up. Posterior lip not felt. Breech is at the inlet. 
No membranes can be felt. The pelvis is not contracted. 

Operative delivery was advised and accepted by the patient 
and her husband. To the latter a guarded prognosis was 
given for the baby because of the long second stage with 
ruptured membranes and for the mother probability of severe 
lacerations. 

I watched the patient through two pains while the prepara- 
tions for delivery were completed and there was no gain made. 

When the preparations for delivery were entirely completed 
the patient was put across the bed and etherized. Each leg 
was held by a nurse, the patient being in moderate lith- 
otomy position. The vulva was carefully prepared after the 
patient was etherized. 

The perineum was carefully dilated, but before it was pos- 
sible to get one's hand inside the vulva the external perineum 
tore like blotting paper to the sphincter. Perineum dilated, 
the anterior lip of the cervix was then readily pushed up from 
between the breech and symphysis. The position was S. L. A. 
and the breech was at the pelvic inlet and was without 
difficulty displaced so that the left hand at once reached 
the anterior thigh. This was followed up until the popliteal 
space was reached. The femur was then pushed inwards on- 
to the baby's abdomen. The heel dropped downwards and 
was at once grasped. No contraction ring was present. The 
anterior leg which was the one seized was brought down with- 
out difficulty. As the buttocks appeared at the vulva the 
tear in the perineum increased. The right index finger was 
hooked into the posterior groin and by combined downward 
traction on the left leg and posterior groin the buttocks were 
delivered with but slight difficulty. The transverse diameter 
of the baby's pelvis was kept in the left oblique diameter of 
the mother's pelvis. The baby was grasped about the pelvic 
girdle with the operator's two thumbs side by side over the 
baby's sacrum. By lateral flexion and traction downward 
the spines of the scapulae appeared at the vulva. The legs 
were then with the left Jiand drawn upward and outward to 



BREECH DELIVERY. 1 85 

the patient's right side giving more room at the perineum to 
seek, with the right hand, the baby's right, or perineal arm. 
This arm was partially extended and it was delivered with 
a great deal of difficulty. The baby's feet were then grasped 
by the right hand, drawn downward and outward to the 
mother's left and with the left hand, the anterior or left 
arm was sought. It was found fully extended, and as I went 
up over the anterior shoulder to the arm I was unable to 
bring it down. With my left hand over the anterior shoulder 
and my right hand below the right shoulder I turned the baby 
from right to left. By this turning the anterior arm, the 
left, was made the perineal. The legs were then held strongly 
upward and outward to the patient's left and with the left 
hand the arm was then readily delivered. From the time the 
operator's hand was pushed upward through the cervix until 
the delivery of the arms was begun, strong pressure was given 
by an assistant on the fundus. The arms delivered, the baby 
was grasped in the same manner as described on page 177, 
except that it was placed on the left forearm. With com- 
bined traction and suprapubic pressure the head was brought 
well down into the pelvis. On the second traction downwards 
and with two fingers on the floor of the baby's mouth to gain 
all the flexion possible the head was delivered. The cord 
was pulsating and the baby gasped at once. It was thorough- 
ly drained and in a few seconds it cried. The baby moved 
both arms and legs well. The cord was tied and cut and the 
baby put safely away. 

Examination of the perineum showed a deep tear on the 
patient's right, the sphincter was torn through and the tear 
extended one-half inch up into the rectum. 

The cord, wrapped in a sterile towel, was pulled taut and 
held out of the way and above by the nurse. A gauze sponge 
soaked in 70% alcohol was placed in the vagina to keep the 
perineal tear in clear view. Perineal tear wiped off carefully 
with 70% alcohol. Two No. i plain catgut sutures were 
passed through the edges of the rent in the rectum and tied 
on the rectal side. Two buried No. 2 chromic catgut sutures 
were then placed, bringing together the deepest portion of 
the perineal tear. Four No. 2 chromic catgut interrupted 



1 86 CASE HISTORIES IN OBSTETRICS. 

sutures were passed from the vaginal mucous membrane 
surrounding the tear and brought out on the opposite side 
of the tear in the vaginal mucous membrane. The highest 
suture was placed first and tied, then in turn the three others; 
these approximated the internal tear. The torn ends of the 
sphincter were now seized with a rat -tooth forceps and three 
interrupted sutures of chromic catgut No. 2 brought the ends 
well together. The sponge was now removed from the vagina 
and the placenta came away. Inspection of it showed it to 
be intact with all the membranes. One silkworm-gut suture 
was now placed in the external perineum so as to include the 
torn sphincter as a supporting stitch. Three others were in 
turn then placed and the external perineum brought into 
approximation. These sutures were all tied without pressure 
on the tissue because of the edema which was already present. 
Vulva then cleaned up and sterile pads placed over it. 

Patient made a good recovery from ether. No vomiting. 
The uterus was held for forty minutes and it stayed well con- 
tracted. Patient's pulse when she came out of ether was 120, 
occasionally rising to 130 or dropping to iio. It remained 
of good quality. There was no bleeding. The baby was in 
excellent condition and weighed eight pounds. 

January 29. Telephone from the physician in charge 
saying the temperature was practically normal, pulse coming 
down in rate. Lochia normal. No tenderness over the 
uterus. Stitches looked well. No edema. Is passing urine 
and the milk is coming into the breasts. 

February 2. Evening of the sixth day. Telephone 
from the attending physician saying ^'the patient is not doing 
as well" as he would like and wanted me to see her. Tem- 
perature he said to-night jumped to 103.4°, with rise in pulse 
to 120. The perineal stitches looked as if they had not ''held.'* 

I saw her the next morning. She was smiling but she 
looked sick. Her temperature was 101°, pulse 130, regular, 
of good volume and tension. Breasts were full but soft. 
The baby was nursing regularly every two hours. Abdomen 
was slightly distended. Tympanitic. There was no tenderness 
anywhere in the abdomen. The uterus was hard and con- 
tracted to one and a half inches above the symphysis and not 



BREECH DELIVERY. 187 

tender. There was no tenderness in either kidney region. 
From examination thus far I felt confident that the source of 
the trouble was not uterine. Patient then placed across the 
bed in lithotomy position. 

Lochia is contaminated with feces and feces are seen over 
the lower part of the vulva. Vulva carefully cleaned and 
labia separated, and it is at once seen that the perineum has 
sloughed. Palpation with finger on the left of the perineum 
gave no tenderness but on the patient's right there was ex- 
quisite tenderness. External stitches except the one in the 
sphincter removed. Bivalve speculum introduced into the 
vagina and a dirty, foul sloughing mass at once appeared. 
With my finger I laid the tear open to the base, wiped it 
out with sterile gauze and then with 70% alcohol and packed 
the tear wide open with iodoform gauze. Feces were found 
coming through the perineum just above the sphincter. I 
did not see the cervix. I suggested that her shoulders and 
body be raised in order to favor drainage. No stimulation 
now advised. Bowels to be kept free. The diagnosis is 
clear. Sepsis from a perineal tear. 

The next morning the temperature and pulse dropped. 
For a few days she did well but then began to run a slight 
temperature and a rising pulse. I did not see her again but 
the physician in charge reports that she had a long drawn out 
sickness, marked right-sided pyelitis, and a double phlebitis 
but that now in April, she is well, has control over her sphinc- 
ter, and there is no leaking of feces through the vagina. She 
has no discharge and has no bearing down sensations in the 
vulva. Considers herself as well as ever and the baby has 
done consistently well on modified milk. There is no doubt 
that later this patient will have to have her perineum 
repaired. 



1 88 CASE HISTORIES IN OBSTETRICS. 

Case 27. Breech. Voorhees Bag. The patient is 
twenty-four years old. She is at term in her second preg- 
nancy. The first ended in a miscarriage at three months, 
cause of which is unknown. She entered the hospital at ten 
o'clock on the morning of November third. Labor, she said, 
began about two a.m. ; the pains were not severe, but were 
sufficiently hard to prevent her from sleeping. Palpation 
showed the position to be S. D. A. The breech was firmly 
engaged at the inlet. Uterus was contracting and relaxing 
well. Fetal heart was 144 in the right upper quadrant. The 
baby is small. Membranes unruptured. Pelvic measure- 
ments are normal. Patient's pulse is 76. Temperature 
98.6°. No vaginal examination made at this time. Obser- 
vation over the next hour showed the pains coming every 
eight to ten minutes and apparently of increasing severity. 
By three p.m. the pains were of five-minute intervals lasting 
one minute. The uterus continued to relax well. Fetal 
heart stayed at 140-150, patient's pulse 80. From now 
to eight P.M. labor continued active and the patient began 
to cry out with each successive pain. At eight p.m. the house 
officer reported that vaginal examination showed the breech 
to be well engaged, the cervix taken up and the os dilated 
but one inch. Membranes unruptured. Fetal heart 146. 
Patient's pulse was 108. The uterus was soft between pains. 
The patient was crying out loudly with each pain and it was 
evident she was losing her self-control. I advised the house 
officer to put in at once a large-sized Voorhees bag under 
ether. He at once made the necessary preparations and by 
nine p.m. she was out of ether with the bag within the cervix. 
In passing the bag through the cervix the house officer 
ruptured the membranes but very little liquor came away. 
Pains did not cease, but continued coming in decreasing in- 
tervals. Pulse immediately on coming out of ether was 120 
but it very soon dropped to 100. Fetal heart remained at 
148. At ten-thirty the bag came out over the perineum. At 
eleven the breech appeared at the vulva. She worked well 
with each pain and steady progress was made. Fetal heart 
remained regular. She was now put across the bed and her 
legs held in lithotomy position by the nurses. With each 



BREECH DELIVERY. * 1 89 

pain ether was given her. She steadily pushed the breech 
further into view. As the breech crowned she was under full 
anesthesia. There was no difficulty in the delivery of the 
buttocks and legs. The arms were found flexed on the chest 
and were readily delivered. With gentle traction combined 
with suprapubic pressure the head was readily born. The 
baby cried at once and when the cord stopped pulsating it 
was tied, cut and the baby put aside. 

Inspection of the perineum showed a moderate second - 
degree tear. Three silkworm-gut sutures were at once 
placed so as to surround the base of the tear. Fifteen 
minutes after the baby's birth the placenta came away 
spontaneously, intact with all the membranes. The perineal 
stitches were then tied. The patient carefully cleaned up, 
sterile vulval pad placed and she was put back to bed in 
excellent condition. Pulse 112. The baby weighed 6 pounds 
and 6 ounces. 

The patient made an excellent convalescence, nursed her 
baby and it did well. Stitches were removed on the eighth 
day. She got up out of bed the twelfth day. Examination 
the thirteenth day showed the perineum well healed. Uterus 
normal in size and position, freely movable. Slight bilateral 
tear of the cervix. Vaults free. No flowing. She was 
discharged on the fourteenth day, both she and the baby 
well. 



Summary of Breech Delivery and Extraction. 

The successful management of a breech labor may at any 
moment tax the ability and judgment of the physician in 
charge. The laity have come to regard the loss of a baby 
when the birth is by the breech as a usual occurrence. 
Physicians have enlarged upon this so that now one may 
constantly hear that this presentation alone is the cause 
of the death. I do not care who is in charge of a breech labor, 
that physician may occasionally lose babies from this pres- 
entation, but by far the large majority of babies are lost 
because of bad management from start to finish. Bad man- 
agement is not blamed, but the physician is ever ready to 



190 CASE HISTORIES IN OBSTETRICS. 

hide behind the idea that the laity expect babies to be lost 
from this presentation. 

In the management of a breech presentation the question 
arises at the outset as to when a physician should go to such 
a case after labor has begun. The author feels strongly that 
in such cases the physician should go at once. The phy- 
sician's place is with the patient because of the well-known 
facts of the added risks such a presentation carries. At any 
time in the labor active interference may be necessary if a live 
baby is to be obtained. No physician can tell when that 
will come. Watchful preparedness must be kept. If the 
physician cannot go he is bound, in my opinion, to send 
someone else as competent as he to stay with the patient 
until he can get there. The busy practitioner will say at 
once that he cannot afford to spend so much time on an 
obstetrical case. The answer to this is plain, that if there is 
a bad result, the blame must be entirely his and not that of 
the presentation. 

The question of assistance is one of great importance. A 
breech delivery should never be attempted without skilled 
assistance. The author has never yet been in the predica- 
ment of having to deliver a breech alone. Careful ante- 
natal examination will give the diagnosis of the presentation. 
Help from a nearby physician can° always, except 
in remote country districts, be arranged for if the physician 
wishes it. One may say that the family cannot afford to pay 
a second physician for his time. If this is the case, give the 
assistant part, or even the whole, of your fee and have the case 
go well. If you put it only on a selfish basis in the long run 
such an attitude pays. If you are away in the country either 
take a younger physician with you, or have him in close tele- 
phone connection so that you can get help quickly. Certain 
physicians will say that having a second physician is absurd, 
an unwarrantable expense, an unnecessary added fear to the 
patient. These reasons weigh little with a successful result 
in the balance. 

Careful watching of the fetal heart and the recording of it 
is important. A rise of a few beats usually is not of impor- 
tance, but a steady slight rise is indicative of probable danger. 



BREECH DELIVERY. I9I 

When the membranes are unruptured, auscultation of the fetal 
heart once an hour if there is no change is usually sufficient ; 
if there is any alteration, then oftener, as the occasion may 
indicate. If the patient is in active labor and membranes 
are ruptured then listen to the fetal heart at least every half 
hour. The moment the membranes rupture, the fetal heart 
should be listened to. It must be remembered that the loss 
of the fetal heart is not necessarily an indication of the death 
of the fetus. On the other hand, the steady rise, or irregu- 
larity in the beats calls frequently for active interference. 
The well-known danger, but often not appreciated, of pressure 
on the cord in footling presentations must be kept in mind 
and will many times mean very frequent observations of the 
fetal heart even to the annoyance of the patient. 

The careful use of obstetrical ether in a breech is just as 
permissible as in a vertex presentation. There is absolutely 
no reason why it should be withheld. 

The question is sometimes raised, ''why not perform an 
external version before labor starts up?" The consensus of 
opinion is that many times it is impossible ; that when it is 
possible the conditions which made the presentation a breech 
still being present will return the fetus to its first position. 
In a multigravida known to have sufficient pelvic room there 
is no indication for even thinking of an external version for 
if breech presentations in such patients are well managed 
there should be no mortality or morbidity. If an external 
version is attempted, there unquestionably is a risk of entan- 
gling the fetus in its umbilical cord and the loss of the baby 
from this procedure would be a great blow. 

A certain few breech presentations undoubtedly do turn 
spontaneously and become vertex presentations, or the ver- 
sion may be vice versa as above noted, page 175. The author 
questions the statement that vertex presentations become 
breech presentations after labor i«s well established. The 
probability of an error in diagnosis is too great. The rupture 
of the membranes at the onset of a breech labor may increase 
the risk to the baby many times, because of the necessity of 
operative interference. The breech is not a good dilator. 
Such labors may be slow and without advance. But as above 



192 CASE HISTORIES IN OBSTETRICS. 

recorded (Case 24) progress may be satisfactory even in a 
primipara. 

The author does not allow patients with breech presenta- 
tions with a constant oozing away of the liquor, up and about 
the room, much preferring to keep in utero what liquor is 
left as a protection to the baby rather than to hurry labor by 
walking the patient about. When the membranes rupture 
early and satisfactory progress is not made the introduc- 
tion of a dilating bag works beautifully in many cases and 
oftentimes makes the delivery as noted in Case 2*] very easy. 
Had the attending physician in Case 25 introduced the 
dilating bag when labor was advancing irregularly and poorly, 
undoubtedly dilatation would have been complete hours 
earlier and in all probability the contraction ring which pre- 
vented him from delivering the baby would not have been 
present, at least it would not have been so tight that with 
justifiable force he could not have dilated it. 

The author recognizes that this suggestion of introducing 
a dilating bag is far removed from the usual teaching of leaving 
breech presentations severely alone, on the ground that in 
time they will deliver themselves without disaster. The 
author appreciates the fact that the average breech labor in 
a primipara or multipara is usually slower than when the 
vertex presents. When progress as shown by the dilatation 
of the OS uteri or descent of the breech is steady and the type 
of labor is normal (see page 175) then only watch the patient, 
but be prepared. On the other hand, when progress is not 
made, find out why it is not and plan the conduct of the case 
accordingly. If you wait until one or the other of the patients 
is in poor condition you will be forced to operate in the end 
and the result can in all probability be but poor. In other 
words, interfere only when you are certain that progress is not 
being made. The more skillful the physician the sooner is 
he justified in operating. Every physician who undertakes 
an obstetrical case must be able to recognize progress or non- 
progress. If he is not sufficiently well trained to attempt the 
procedure indicated he must be willing to send for help early 
so that the consultant will have at least an even chance to do 
his work well. 



BREECH DELIVERY. 193 

The same instruments should be ready for a breech delivery 
as for a forceps delivery (page i6o), with the addition possibly 
of a blunt hook. Few physicians carry with them a blunt 
hook, possibly because of the danger its use entails. The 
blunt hook which supply houses usually carry is of a poor 
type. The diameter of the curve is much too small, making, 
in all but very small babies, pressure in the groin over the 
femoral vessels. If one is to be used the curve should have 
a diameter of two inches so that the leg is surrounded. Oppo- 
site to the hook at right angles to it should be a handle and 
not the old-fashioned crotchet. If, as is often the case, the 
physician does not see that means to resuscitate the baby 
(page 478) are at hand, he should never fail to have them 
ready in a breech delivery, no matter how simple he thinks 
it is to be. 

Besides the above-mentioned aids a pail of sterile hot water 
or hot corrosive solution 1-3000 and three or four sterile 
towels must be ready. The towels are used either wet or 
dry as the physician elects. Their use is two fold, first to give 
the operator means to grasp firmly the leg or body in order 
to prevent slipping and second if used wet and warm to help 
prevent the baby taking the first inspiratory gasp while the 
head is in utero. 

The relationship of the size of the baby in breech presenta- 
tion to a given pelvis is much more difiicult to determine 
than in a vertex presentation because of the far removal of 
the head from the pelvis. This fact is no reason, however, 
for not making as careful measurements of the pelvis as is 
possible. If the relation between the fetus and the pelvis 
is close then may arise the question of a Csesarean section ; if 
disproportion is present Csesarean section becomes without 
a doubt the elective means of delivery. 

All patients with breech presentations should be delivered 
in the dorsal position. The legs, if possible, should be held, 
not necessarily by trained assistants. If this cannot con- 
veniently be done, a leg holder, or even the backs of two 
straight chairs may be used. 

The author firmly believes that all breech cases at the final 
expulsive stage should be under complete anesthesia. I 



194 CASE HISTORIES IN OBSTETRICS. 

admit that occasionally it may be unnecessary, but I have too 
often seen physicians try to deliver the arms and the after- 
coming head in cases without ether and then hurriedly and 
cruelly clap on the ether cone expecting to obtain in a few 
seconds complete relaxation. No one knows when an arm 
will be extended and never can the best intelligent supra- 
pubic pressure be given with the patient straining at the 
utmost with her abdominal muscles. 

In a breech labor the preparations for the delivery, which 
are the same as for any delivery, should have been completed 
much earlier than in a vertex presentation because as I have 
already said the possibility of interference may be necessary 
at any moment. 

The patient during the first stage may elect the position 
she will be in, up and about her room or lying down. As the 
pains increase and she goes to her bed, whether she takes the 
dorsal position or not is immaterial unless she is a multipara 
with a pendulous abdomen; then she should be kept on her 
back. It may even be necessary to draw up by a binder a 
markedly pendulous abdomen and splint it on either side. 
Failure to keep in mind this simple procedure has led to many 
hard operative deliveries. Within a short time I saw this 
procedure strikingly shown. The patient, a multipara, had 
been in the second stage of a breech labor about two and a 
half hours. When I saw her the breech was at the inlet. 
She was in excellent labor but during all of this stage had been 
kept on her left side. The abdomen was very pendulous and it 
was apparent that the excellent pains were accomplishing 
little, if anything. The uterus was working at a great dis- 
advantage. I suggested placing her in the dorsal position 
which was done. In four pains the breech was in the pelvis 
and in a few more the buttocks appeared at the vulva and 
the delivery was accomplished in a few minutes. 

When the perineum is bulging, then at the latest should 
the patient be put in the dorsal position. If obstetrical ether 
has not before this been begun it now may be. As the but- 
tocks come further into view with each succeeding pain they 
are supported or raised slightly upward, — lateral flexion. 
Ether is forced more and more. The legs are delivered at 



BREECH DELIVERY. 195 

all times remembering the anatomy of the joint one is manipu- 
lating. The legs and buttocks delivered then one feels for 
the cord and determines whether it is pulsating or not. To 
place the cord at this point or that, the author believes to be 
unnecessary. Draw it down, so that as the delivery is com- 
pleted, there will be no undue tension upon it. 

The rapidity with which delivery must be accomplished 
depends upon the pulsations or non-pulsations in the cord. 
The bisacromial diameter of the shoulders is kept in one or 
the other of the oblique diameters of the pelvis, depending 
upon which position the baby lies. The perineal arm is first 
delivered and then the anterior (for technique see page 177). 

During the time of the delivery from the beginning of the 
expulsion of the buttocks to the completion of the delivery of 
the arms there should be good pressure on the fundus of the 
uterus. If the operator finds that the arms are extended 
the pressure on the fundus must be very slight. Other- 
wise, the head and the arms will have a tendency to become 
wedged in the pelvic inlet. If the bisacromial diameter of 
the shoulders is coming down in the right oblique diameter, 
the author always places the body of the baby astraddle his 
right forearm with the index and middle fingers in the 
child's canine fossae or in the mouth. The left hand grasps 
the child's neck, the middle finger on one side and the ring 
finger on the other. With this grasp, downward and then up- 
ward traction is carried out, combined with intelligent supra- 
pubic pressure. By intelligent suprapubic pressure, I mean 
well-directed evenly given pressure directly on the vertex. 
This is best obtained as follows : — The patient is across the 
bed in lithotomy position, as I have already said, either with 
the legs held or in stirrups. The assistant who is standing by 
the bed or kneeling on it facing the operator and who has 
been giving fundal pressure, keeps careful watch on each 
movement of the operator. When he sees that the extrac- 
tion of the head is to be begun, with both hands he surrounds 
the head, getting in beneath the placenta, letting the fundus 
for the moment go, pressing directly on the head. His 
extended fingers are in the hollow of the sacrum towards the 
sincipital end of the head. His thumbs are forward over the 



196 CASE HISTORIES IN OBSTETRICS. 

occiput and the moment the operator starts his traction down- 
ward the assistant makes firm pressure with his hands 
downward, more forward with his fingers than with his 
thumbs, thereby keeping the flexion which at first is so 
essential. With pressure from above and traction from below 
the occiput swings around the arch of the symphysis and the 
head is born. The amount of suprapubic pressure necessary 
varies greatly, in some cases practically none is necessary. 
In others the amount necessary is great, and unless it is given 
intelligently the result is oftentimes fatal to the baby. With 
the pressure given as described, the descent of the head is 
most readily appreciated and the amount of force used readily 
graded. There is no danger in leaving the fundus alone for 
the few moments that the extraction of the head requires in 
the majority of cases. Should the extraction of the head 
prove very difficult and require much time, one hand must be 
taken off the head and put on the fundus to hold it down. 
The usual advice pictured in the textbooks shows the pres- 
sure transmitted through the placenta to the head, but in 
the author's hands this method has not been as satisfactory 
or as efficient as the one here described. 

In a breech delivery the forceps must be ready to be applied 
to the after-coming head (see page 245). The most skillful 
obstetricians will at times have to resort to their use and it 
is the author's feeling that less damage is done to the baby 
by their application than by persisting in using an unjustifi- 
able amount of traction on the baby's neck. The author's 
rule is, if after three attempts of combined traction and supra- 
pubic pressure no advance is made he then without hesi- 
tancy, puts forceps to the after-coming head. It is a life- 
saving procedure and its technic must be mastered. 

Forceps to the breech has been advocated but they are not 
moulded for the breech. They have a tendency to slip and 
on the whole are very unsatisfactory. 

Do not interfere with a breech that is progressing satis- 
factorily. Follow carefully its progress. If with a good 
type of labor there is no progress and indications arise for 
interference be prepared to meet any emergency. If you are 
not sufficiently well trained to do the necessary procedure, 



BREECH DELIVERY. 197 

turn to the best man in your neighborhood to help you. Do 
not stand idle when you know the indication for delivery is 
clear. If the membranes in a breech presentation rupture 
early and no progress is made, the early use of a dilating bag 
is of great aid and will many times make what looks to be a 
difficult problem turn out relatively simple. 

All agree that the risk to the baby in any breech delivery 
is greater than in a vertex presentation and because this is 
so it is most important that every possible safeguard be taken 
to obtain a live baby. Even with all possible care a certain 
small number of breech presentations must necessarily be 
lost, but if physicians would be more disposed to criticise 
themselves for the loss of these babies and not blame the 
position of the fetus for the bad result, there would directly 
follow a decrease in the mortality rate. 

There is no gainsaying the fact that the morbidity of the 
child in breech presentations is distinctly greater than in 
vertex presentations. Fractured arms or legs, obstetrical 
paralysis and intracranial hemorrhage are not uncommon. 
In giving the prognosis for the baby to the family in a breech 
extraction it is always best to give a guarded one for the 
physician can never tell what difficulties he may encounter 
before the child is born. This is especially true in a primi- 
parous breech but in a multiparous breech where there is no 
disproportion the prognosis, as has already been said, should 
be absolutely good. 

The prognosis for the mother In a properly managed breech 
labor should be absolutely good ; it is the risk of any obstet- 
rical case. 



SECTION VI. 
MULTIPLE PREGNANCY. 

Case 28. Twins. O. D. A. Low Forceps. S. L. A. 
Breech Extraction. Patient is seen for the first time 
September 3rd. Up to this time she has been in charge of 
the family physician. She is 26 years of age and has been 
married eighteen months. She began menstruating when 
she was 12 years old. Menstruation comes every 28 days, 
with an occasional interval of five weeks. She flows five days. 
Her last normal menstruation was on February 6th. She 
expected to flow early in March but no period came. On 
March 14th she flowed profusely with clots and on the 15th 
she passed one large clot with much ''substance" to it. At 
this time she had a great amount of pain and was in bed for 
two days. On March i6th the flow stopped and she was up 
again on the 17th. She thought, at this time, she had had a 
miscarriage. No physician saw her. She has had no flowing 
since these two days, March 14th and 15th. She herself does 
not think pregnancy started until after the 26th of March. 
If that is so she would not be due for delivery until the end 
of December while if pregnancy began before the period 
skipped in March she would be due in all probability the first 
part of November. She has been perfectly well up to the 
present time. All urinary examinations have been reported as 
normal. Her bowels are moving daily with the aid of cascara. 

Because of this irregular menstruation she decided not to 
engage a nurse until she fell into labor. She was given the 
list of necessary articles for the delivery and told to have 
them in the house by the first of November. 

October 5. Her pelvis was measured to-day: — Crests 
27.5 cm.; spines 24.5 cm.; external conjugate 19 cm. She 
is a small, slight woman with small bones. If she goes until 
the end of December she will have a very large 
baby. From palpation I cannot determine the position, the 

199 



200 CASE HISTORIES IN OBSTETRICS. 

abdomen is so tense. There is a vertex without any doubt 
presenting at the brim of the pelvis. No fetal heart heard 
and no fetal movements felt. 

October 25. For the past few days she has been having 
slight uterine contractions with pain. They are irregular in 
time and severity. They come especially at night, and she 
has been able for the last two nights to get but little sleep. 
She gets up five or six times to urinate and passes but a small 
amount each time. Her pulse is 80 and she is in excellent 
condition. Slight edema is present at the ankles; none of 
the face or of the hands. Palpation to-day shows a large 
abdomen. Fundus is at the ensiform. A hard, firm, round 
mass is to-day readily made out in the left upper quadrant. 
B allotment with this mass is definitely obtained. There is 
smooth resistance both on the right and on the left sides of the 
abdomen. Small parts are palpated in the median line. A head 
is made out entering the pelvis. Fetal heart is heard best at the 
level of the umbilicus one inch to the left, 140 to the minute. 

Vaginal Examination : — Promontory cannot be reached 
because of the head, which is well in the pelvis. Contour 
of the true pelvis is apparently normal. Ischial spines are 
readily palpated. Cervix is soft and flush with the vaginal 
vault. Os admits one finger. Pubic angle is normal. 

A diagnosis of twins definitely made. For her sleepless- 
ness she was given trional gr. x at bedtime. 

November 9. At six this morning she was awakened by 
pains in the abdomen. The pains came for two hours every 
twenty minutes and then stopped. At noon she again began 
to have pains at fifteen-minute intervals, and at one p.m. she 
telephoned to me. I saw her shortly after this and she was 
then having definite uterine contractions every eight minutes, 
lasting but thirty seconds. A nurse was at once obtained 
and the preparations for delivery begun. From four until 
seven she had practically no pains, though the nurse noticed 
a few irregular contractions of the uterus. At seven p.m. she 
started in having hard pains every ten minutes, lasting one 
minute. The uterus contracted well but relaxed poorly. 
By midnight the pains were coming every three minutes and 
lasting a minute. Patient's pulse 90. There was consider- 



MULTIPLE PREGNANCY. 201 

able show. The membranes were unruptured and the fetal 
heart remained 140 to the minute. At no time could I find 
a second fetal heart. 

November 10. 3 a.m. Vaginal examination showed the 
cervix very thin; os uteri three-quarters dilated. A good 
bag of fore waters present and a small head low in the pelvis. 
From now to four a.m. the pains came in decreasing frequency 
and lasted but thirty seconds. The uterus remained tense 
between pains. It was not tender. The pulse had risen to 
no, I then decided to deliver her because of the inefficient 
type of labor and the rising pulse. 

Preparations were completed. Patient etherized, and 
placed in lithotomy position. Scrubbed up. Catheterized. 
Perineum thoroughly dilated. Os found to be fully dilated. 
Membranes now ruptured and position determined to be 
O. D. A. Forceps were readily applied to the small head. 
With the first traction the head at once came in sight. A 
very easy extraction then followed. The baby was a small 
puny thing without strength. It cried feebly at once. The 
cord was clamped twice and cut between. The baby was 
given to the nurse and she carefully did it up in a warm 
blanket and put a hot-water bag near it. As soon as this 
baby was delivered it was at once seen that another baby 
was in utero and the diagnosis of twins confirmed. 

Vaginal examination showed a breech presenting in S. L. A. 
position. Left hand passed into the uterus and the mem- 
branes of the second sack then ruptilred. The anterior 
foot, was found and a breech extraction (see page 189) 
readily done. The arms were not extended and were de- 
livered with ease. There was no difficulty with the after- 
coming head because of the excellent suprapubic pressure 
which was given. When the cord stopped pulsating it was 
clamped and cut. Examination of the perineum showed a 
slight first-degree median tear. 

The uterus acted well and on the fifth contraction expelled 
the placenta. Examination of the placenta showed it to be 
intact with all the membranes. As well as could be deter- 
mined it was one placenta. The babies were both girls. 

The patient's pulse after delivery was 120. There was no 



202 CASE HISTORIES IN OBSTETRICS. 

bleeding and the uterus remained hard and well contracted. 
Ergot was given intramuscularly. The perineum was re- 
paired at once with two silkworm-gut sutures. She was 
cleaned up, a sterile pad put on and at once put back to bed 
in excellent condition. She made an excellent recovery from 
ether without vomiting. 

The first baby was at once oiled, wrapped in absorbent 
cotton and surrounded by hot-water bottles. Its care was 
at once assumed by the family physician who is a children's 
specialist. The seconds baby weighed seven pounds and was 
in excellent condition. It was washed and dressed at the 
nurse's convenience. 

At the evening visit patient had a temperature of 99°; 
pulse 70. She has voided urine. She and the babies are in 
excellent condition. 

November 12. Early this morning the nurse went to 
change the little baby and found it cold and pale. She 
opened the premature jacket and found the diaper soaked 
through with bright red blood and also a large tarry move- 
ment. She at once telephoned to the physician-in-charge 
but the baby died within five minutes. It undoubtedly had 
hemorrhagic disease of the new-born, and the one large 
hemorrhage was fatal. 

The mother is doing well. Temperature 99.2° and pulse 
104 to-night. As yet there is very little milk in the breasts. 
The baby is nursing every four hours and is satisfied. 

November 18. The stitches were removed to-day, ap- 
parently a good result. Baby is nursing regularly every two 
hours and is gaining. There is no vaginal discharge, and the 
uterus cannot be felt above the symphysis. 

November 30. The patient has made a uniformly good 
convalescence. She got up to-day, the twenty-first day. 
From now on she is to get about more and more. 

December 10. Vaginal Examination: — Perineum well 
healed. Cervix shows a stellate tear. Uterus is normal in 
size and position. Is freely movable. There is no tender- 
ness in the pelvis. There is a slight leucorrhea present. 
Both she and the baby are in excellent condition and are dis- 
charged to the family physician. 



MULTIPLE PREGNANCY. 203 

Case 29. Twins. O. L. A. O. D. P. Normal Deliveries. 
Patient is eight months advanced in her fourth pregnancy. 
Three previous pregnancies have all been normal and she 
delivered herself very readily after short labors. The chil- 
dren weighed at birth between 7 J and 8 J pounds. At the 
first delivery she was badly lacerated and she said that five 
external stitches were placed. In the present pregnancy 
there is nothing of interest to note. She is due for delivery 
according to her menstrual periods December 29th. Decem- 
ber 26th at 2:30 A.M. the husband of the patient telephoned 
that his wife was having a few pains and that the waters had 
broken at eleven o'clock December 25th, and that now a 
slight amount of blood was coming away. I saw her at 3 130. 
At that time she was having no pains and had had none 
for the past half hour. Palpation shows a large abdomen. 
Definite diagnosis of position is difficult to determine. Un- 
questionably there is a head presenting and there is firm 
resistance along the left side of the abdomen. There is also 
firm, smooth resistance on the right side of the abdomen and 
it is a question whether there is not a head low down on the 
right side. Fetal heart is heard distinctly in the left lower 
quadrant, 120 to the minute. No other fetal heart can be 
heard in any part of the abdomen. Fetal motion is seen in 
the median line and here definite motion can be felt. There 
is a probability of twins but as she is a difficult patient to 
palpate and as a second fetal heart is not heard, a definite 
diagnosis is not made. The head is not firmly engaged in 
the pelvis and because the membranes had ruptured I made 
a vaginal examination at once and found a good -sized head 
presenting, only lightly engaged. Os uteri was dilated to 
the size of a fifty-cent piece but the cervix was thick. No 
cord was felt. From four o'clock until six she had no pains 
or contractions of the uterus. Shortly after six she began 
having pains every ten minutes lasting one-half to three- 
quarters of a minute. From now on she had increasingly 
severe pains. At eight o'clock she began to bear down with 
each pain and from the character of her pains it was quite 
evident that she must be beginning her second stage. Pre- 
parations for delivery were quickly completed as previously 



204 CASE HISTORIES IN OBSTETRICS. 

described. I had nobody to help me but the husband as this 
was one of my earliest cases. About half past eight the 
perineum began to bulge and she was at once put into the left 
lateral position and urged to bear down with each pain. 
She very quickly brought the head to the vulva; as the peri- 
neum had been badly lacerated there was a very short 
perineal stage. No ether was given. She was made to pant 
and gradually the head was delivered. It restituted to her 
left and the labor was therefore from an O. L. A. The baby 
was large, a boy, and cried at once. The cord was pulsating. 
Because of the suspicion of twins care was taken to put two 
clamps on the cord as it stopped beating, and the cord was 
cut between them. I immediately grasped the fundus as 
soon as the child was born and it was very evident that there 
was another baby in utero. The first baby was put aside, 
carefully wrapped up in a blanket with a hot-water bottle 
beside it. Palpation of the uterus showed the second baby 
presenting by the vertex. Pains did not begin again for 
one-half hour after the delivery of the first baby, but they 
then began again with excellent contractions and in three- 
quarters of an hour she again began to bear down. The 
membranes of the second sac had not ruptured. I examined 
the patient and found that the head was in the pelvis and I 
then ruptured the membranes. Pains then ceased for twenty 
minutes when she had one severe pain and the perineum be- 
gan to bulge. She was made to pant and with the next pain 
she pushed the head so far down that it could be held from 
behind the anus. She continued panting and the head was 
then delivered between pains as described in the normal 
deliveries. The occiput restituted to her right. The shoul- 
ders and body of the baby followed at once. It was another 
boy. I at once grasped the fundus of the uterus with my 
left hand and it was found to be firmly contracted but large 
and I then put the patient's hands down on the fundus and 
told her to keep them there until I told her she could let go. 
The cord was pulsating and as soon as it stopped pulsating 
was clamped and the baby was put away. Patient was 
then turned as previously described onto her back. A fresh 
sterile pair of gloves put on and half an hour after the delivery 



MULTIPLE PREGNANCY. 205 

was completed the placenta came away intact with all the 
membranes. There was one placenta and two amniotic sacs 
and apparently it was intact with all the membranes. The 
uterus acted well but because of the distention of the uterus 
I gave her ergot intramuscularly. She was cleaned up and 
put back to bed in excellent condition. Pulse of 80. Tem- 
perature taken before I left was 99.2°. There was no bleed- 
ing and I left her two hours after the delivery was completed 
in excellent condition. The babies weighed 7§ and 7 
pounds. Both were boys and physical examination showed 
them to be normal. There was milk in the breasts and late 
in the afternoon of the 26th both babies were put to the 
breast and nursed well. The milk came in on the second day. 
The patient made an absolutely normal convalescence. She 
had a great quantity of milk and was able to nurse both 
babies. Patient remained in bed ten days and then got 
up and went about her work. Vaginal examination at the 
end of three weeks showed previous perineal tears. Uterus 
slightly subinvoluted. Normal in position and not tender. 
Nothing felt on the sides. Breasts in excellent condition. 
Both babies have done well. Each umbilicus is healed and 
solid. Patients are discharged. 



206 CASE HISTORIES IN OBSTETRICS. 

Case 30. Twins. Double Footling. Extraction. 
Sc. L. A. Version. Patient is seen for the first time when 
she presents herself at the hospital in active labor. She says 
she is at full time. This is her eighth pregnancy. Previous 
pregnancies have all been normal and the deliveries very 
rapid and easy. She is in such active labor, pains coming 
every two minutes and lasting one minute, that satisfactory 
palpation is impossible. The abdomen is very large and dis- 
tinctly irregular in outline and two hard firm round masses are 
felt above the umbilicus, one in the right upper quadrant and 
the other one in the left but lower than the first. Diagnosis 
of twins made and as the membranes had ruptured and the 
patient was in active labor she was examined at once by 
vagina. Both feet were found presenting and the os uteri 
was fully dilatable and very thin. Perineum was relaxed and 
showed previous severe tears. Preparations for delivery were 
quickly completed and she was told to pant with each pain 
until the instruments were made ready. When the prepara- 
tions were complete the patient was put across the bed and 
scrubbed up carefully and the vulva surrounded by sterile 
towels. The legs were held by nurses. At each pain she 
was urged to bear down. Steady progress was made and both 
feet appeared at the vulva. Circulation good. With each 
succeeding pain the legs were forced further into view. They 
were simply supported, — held up off the perineum. It was 
evident that the baby's body was coming down in the left 
oblique diameter. As the thighs appeared the patient was 
given ether with each pain so that by the time the buttocks 
were at the vulva she was almost under complete though light 
anesthesia. Ether was forced and as the body came over 
the perineum she was completely relaxed. A very easy 
typical breech delivery was then done without the slightest 
difficulty. There were no fresh tears. The baby, a girl, was 
drained ; she cried at once and the cord was clamped in two 
places and cut between. 

It was now very clear that there was still a large baby 
within the uterus. Patient still etherized and vaginal ex- 
amination showed a transverse presentation with the back 
anterior, occiput on the left, and the right shoulder, the lower 



MULTIPLE PREGNANCY. 207 

one. I now ruptured the membranes and seized a foot. I 
then told my assistant which way the head would go, namely 
upward on the mother's left. Traction downward on the 
foot made progress but it was at once seen that the foot drawn 
down was the posterior. I then explored the vagina with my 
right hand to see if I could reach the anterior foot. It was 
found at the pelvic brim. This was now brought down and a 
breech extraction done. The bi trochanteric diameter came 
down in the right oblique diameter. The left arm was the peri- 
neal arm and it was readily swept down from its extended posi- 
tion, over the face and chest and delivered. The right arm was 
now sought and it was found to be behind the occiput in the 
so-called nuchal position. The baby's body with the opera- 
tor's right hand on its right shoulder was then rotated to the 
operator's right making this right shoulder the perineal. The 
pelvis was so large and the introitus so relaxed that the fingers 
of the right hand were passed up over the baby's shoulder 
without difficulty to the arm and by pressure downwards the 
arm was flexed, the elbow reached and the forearm swept 
downward over the face and out. With very slight supra- 
pubic pressure the head was then readily delivered. The 
baby cried at once; it was another girl. The placenta at 
once appeared at the vulva. The cord was clamped and cut 
and the baby put aside. As the placenta was in the vagina, 
it was then delivered and there followed at once much bleed- 
ing. The patient was at once given a hot, iio°, intra-uterine 
douche of corrosive sublimate i- 10,000 and aseptic ergot 
intramuscularly. The uterus very quickly contracted and 
the bleeding ceased. Examination of the perineum showed 
no fresh tears. The patient was cleaned up, a sterile pad 
put on and she was put back into bed with a pulse of lOO, in 
excellent condition. 

The uterus was large and relaxed frequently and there was 
continual oozing from the vagina. The uterus was carefully 
held and with ice to the fundus and a second dose of ergot it 
gradually began to act better. The pulse steadily dropped 
and one hour after delivery was 74. The uterus was well 
contracted and there was only a normal amount of bleeding. 
Her binder was then put on. The babies were weighed and 



208 CASE HISTORIES IN OBSTETRICS. 

the first weighed seven pounds and fifteen ounces and the 
second eight pounds and on'e ounce. The entire length of 
labor was three hours and a half, as nearly as could be deter- 
mined. There was milk in the breasts and after she had had 
a rest the babies were put to the breast. She made a per- 
fect convalescence, nursed both the babies and they gained 
steadily after the initial loss. She and the babies went out 
of the hospital on the fourteenth day in excellent condition. 

Summary of the Management of Multiple Pregnancy. 

The diagnosis of twins may be very easy as it was in 
Case 28. Here a head could be palpated entering the pelvis 
and another was at the fundus of the uterus. The very large 
size of the abdomen was suggestive of twins in Case 30. If 
two fetal hearts can be heard at different rates at the same 
time the diagnosis may be definitely made, but because only 
one is heard, twins cannot be ruled out. There always is the 
possibility of twins being present and for that reason the cord 
should be clamped in all cases until it is certain that there 
is not a second baby present. 

The prognosis in twin pregnancies properly managed should 
be absolutely good, — the risk of any obstetric case. Greater 
care must be exercised during the third stage and immediately 
after it. Because of the over distention that the uterus has 
been subjected to there is an increased risk of post-par turn 
hemorrhage. Had Case 28 been allowed to drag on in de- 
sultory labor indefinitely, the danger of a post-partum hemor- 
rhage would have been greatly increased. She would have 
been in far greater danger than she was from an operative 
delivery when she was in good condition. In multiple preg- 
nancies the labor may be slow; on the other hand it may be 
very rapid as it was in Case 30. The uterus often doe!s not 
act well because the distention is so great that it cannot 
contract. If the patient is etherized for the delivery of the 
first child as two of the above cases were, it is better judg- 
ment to deliver the second baby at once and not allow the 
patient to come out of ether and wait for labor to start up to 
expel the second child. 



MULTIPLE PREGNANCY. 209 

If the patient delivers herself there usually is an appreci- 
able time between the birth of the two children while the 
uterus rests. This is well shown by Case 29. Do not hurry 
the delivery of the second twin. Let the uterus rest; it will 
begin to contract again very shortly. If by palpation or 
vaginal examination you find a vertex presentation do nothing 
for at least half an hour; then, if there are no pains, rupture 
the membranes and await developments. I have never seen 
a case of twins where the pains ceased entirely and no attempt 
was made to expel the second child. Should it happen and 
operative interference be demanded, the danger of post- 
partum hemorrhage is much increased and the uterus must 
be carefully guarded. 

If the second twin presents transversely or any part pro- 
lapses, operative interference is demanded unless by manipu- 
lation, external or internal, the presentation can be corrected. 
If the breech presents, unless the baby is very small, etherize 
the patient as the buttocks appear. (See management of 
breech.) The preparations for a multiple delivery are the 
same as for a normal delivery. The means to meet any pos- 
sible post-partum hemorrhage must be close at hand. The 
use of ergot intramuscularly is advisable in these cases, be- 
cause of the unusual amount of distention to which the uterus 
is subjected. 

The physician must remain with the patient until the 
uterus acts satisfactorily. In Case 30 the spontaneous de- 
livery of the placenta was followed by sharp bleeding which 
was quickly controlled by an intra-uterine douche. The 
tendency of the uterus in these cases of multiple pregnancy 
after delivery is to relax and to allow oozing to take place. 
In these cases hold the uterus yourself and never delegate 
this important part of the confinement to anyone else. As 
already spoken of in normal deliveries, watch the maternal 
pulse from the moment the first child is delivered. Unless 
you know what the pulse is at the end of the delivery you at 
once are at sea as to the patient's condition. 

The interlocking of twins is fortunately a rare occurrence, 
but one must always have the possibility of such a complica- 
tion in mind. If there is delay or an undue amount of force 



210 CASE HISTORIES IN OBSTETRICS. 

necessary to bring the first baby down, be sure that inter- 
locking is not present before you exert force. Traction down- 
wards on the first twin may be the wrong procedure. 
Each case has its own problems and a quick grasp of the 
situation will be necessary to carry out successfully any 
manoeuvre. 



SECTION VII. 
PROLAPSED CORD. 

Case 31. Prolapsed Cord. Version. The patient is 
first seen in consultation on September 25th at six p.m. The 
physician-in-charge gives the following history : — The patient 
is at term in her first pregnancy. Membranes ruptured with- 
out warning, September 24th at eight p.m. September 25th 
about midnight pains began. Between five and six they 
became hard and came at twenty-minute intervals. Ex- 
amination then by the physician-in-charge showed the head 
high, dilatation one finger. Cervix partially taken up. She 
went on throughout the day of the twenty-fifth having pains 
every five to eight minutes and lasting one to one and a half 
minutes. At 5 p.m. he said the os uteri was two inches dilated. 
Uterus was relaxing between pains poorly and was slightly 
tender in the lower uterine segment. Pulse was rising and in 
the past two hours had gone up twenty beats and was now 
100. At six P.M. I found the uterus very tender. No con- 
traction ring was palpable. Fetal heart left lower quadrant, 
120 to the minute. Position not determined but a vertex 
presentation. Vaginal examination showed tight perineum. 
Biparietal not yet through the brim. Cervix very thin. Os 
dilated two and a half inches. Anterior fontanelle felt on the 
left, making the position a probable O. D. P. slightly extended. 
Pulse 120 and of good quality. I advised delivery because 
of the very slow progress, the increasing tenderness of the 
uterus, and because of the rising pulse. 

Patient was etherized and prepared in the usual manner. 
Catheterized. Dilatation of the perineum and of the cervix 
completed. In making the diagnosis of the position I found 
a loop of pulsating cord down beside the head. This I 
attempted to replace and on the second attempt another 
loop came down beside the head. Further examination 
showed there were two loops of cord around the neck. Cord 



212 CASE HISTORIES IN OBSTETRICS. 

was pulsating regularly and strongly. Forceps were con- 
tra-indicated, and I therefore at once decided upon a ver- 
sion. With fundal resistance, the right hand was pushed 
upward into the uterus and a foot, which proved to be the 
anterior one, was readily obtained. Version readily done as 
far as the spines of the scapulae, the bitrochanteric diameter 
coming down in the left oblique diameter of the mother's 
pelvis. The right arm, which was the perineal one, was ex- 
tended, but was readily brought down as described in breech 
delivery. The left arm was also extended ; this I was unable 
to turn to make it the perineal arm and with much difficulty 
brought it down from the anterior position by going up with 
the left hand over the left shoulder. The child's body was 
lowered and drawn to the mother's left in order to gain room. 
The extended arm was then flexed by pressure on humerus 
with the operator's left hand and the forearm swept down 
over the face. The head was delivered readily with the aid 
of suprapubic pressure. Baby gasped at once. The cord 
was not pulsating and was clamped and cut. The baby was 
put into a pail of hot water and it soon began to cry lustily. 
Examination showed that the left clavicle was fractured and 
the baby moved its right arm poorly. The baby was carefully 
put aside after being drained and surrounded by heaters. I 
then scrubbed up again and with a clean pair of gloves exam- 
ined the perineum which showed a severe tear in the right 
sulcus with a slight one on the left. Tear of the perineum into 
the sphincter but not through it. Right sulcus was repaired 
with interrupted chromic catgut sutures as was also the left 
tear. Two stitches of chromic catgut were placed in the torn 
fibres of the sphincter and brought the sphincter well together. 
One silkworm-gut suture was put through the torn ends of 
the sphincter as a supporting stitch. Three silkworm-gut 
sutures were placed externally, but were not tied. Patient 
now had a pulse between 120 and 130, but there was no bleed- 
ing and the uterus was contracting well. Placenta was 
delivered intact with all the membranes twenty minutes later. 
There was no bleeding and the uterus acted well. The silk- 
worm-gut sutures were now tied loosely as there was much 
edema already present. A small fibroid the size of a walnut 



PROLAPSED CORD. 213 

was felt on the right posterior surface of the uterus. Patient 
made a good recovery from ether but ran a pulse of 140 for 
a short time. When I left two hours after delivery the 
patient was in good condition with pulse of 120, out of ether, 
uterus firmly contracted and there was no bleeding. 

September 30. The patient has made a fair convalescence. 
Her bowels have not moved since the delivery until to-day, 
when she had a slight involuntary movement. The stitches 
are reported as looking clean. There is but very slight 
tenderness in the perineum. 

October 5. Stitches were removed to-day by the patient's 
physician and a very poor result obtained. There was ap- 
parently little or no attempt at healing as far as the external 
laceration was concerned. The sphincter, however, is com- 
petent both for gas and feces. 

Six months later the husband comes into the office and says 
that the baby has done uniformly well, moves both arms 
equally well and that his wife is having no discomfort from 
the tears, and is in excellent condition. 



214 CASE HISTORIES IN OBSTETRICS. 

Case 32. Prolapsed Cord. Version. Patient was seen 
for the first time by me August 22 at 1 1 a.m. in answer to a 
telephone message from an out-patient house officer that an 
externe had just reported a case of prolapsed cord in a multi- 
para. When I got to the house I found that a second ex- 
terne had been called after the first had left some two hours 
before, as the first externe did not think the patient was in 
labor. She was at the time the first externe saw her having 
no pains. Shortly after the externe left the patient got out 
of bed and the membranes ruptured. She felt the cord just 
outside the vagina and at once sent to the hospital for help. 
When the second externe arrived the patient was in bed and 
he saw the pulsating cord at the introitus. He put the patient 
at once into the knee-chest position and made ready for an 
operative delivery. The pains began as soon as the membranes 
ruptured. Before I arrived, the house officer had examined 
the patient and found her to be nearly two-thirds dilated with 
a soft cervix. I did not attempt to put back the cord but 
advised that she be etherized and delivered. She accepted 
the advice and as soon as the instruments were boiled and all 
the preparations were ready, she was let down from the knee- 
chest position, turned on her back and immediately ether- 
ized. Vaginal examination then showed a loop of pulsating 
cord in the vagina. This loop was pulled down and wiped off 
with 70% alcohol. Os uteri was fully dilated. The position 
was O. L. A. The perineum was carefully and fully dilated. 
An externe was then asked to give resistance on the fundus as 
the left hand was pushed up through the dilated cervix into 
the uterus and the cord was carried up by the hand. There 
was no contraction ring present. The hand was carried along 
the anterior portion of the body and the anterior leg was 
readily found and its foot seized. The externe was then told 
that the version would be done from the left to the right, 
that is, the occiput being on the left side, would go up on the 
patient's left and the foot would come down on the patient's 
right. Accordingly, as traction was made on the leg down- 
wards the externe put his hand below the occiput and drew 
the occiput upwards towards the fundus. At first there was 
no progress made in turning, but with gradual traction com- 



PROLAPSED CORD. 215 

bined with drawing up by the externe, the foot came down. 
The bitrochanteric diameter of the baby came down in the 
right obHque diameter of the pelvis. Gradually the posterior 
buttock distended the perineum and the left index finger 
was then passed into the baby's left groin and traction 
downward made. Traction in the groin combined with 
traction on the leg and the buttocks were slowly delivered. 
The posterior leg was in complete extension and, remembering 
the anatomy of the joints, it was slowly delivered. The 
pelvic girdle was then grasped as previously described, page 
184, and with traction downward combined with lateral 
flexion the body was quickly delivered. The cord was pal- 
pated and was not pulsating. The extraction was completed 
until the spines of the scapulae were seen. The baby's legs 
were carried upward towards the patient's left and the left, 
the perineal, arm sought. It was found only partially ex- 
tended and as the fingers of the left hand went up over the 
shoulder and came down into the elbow, with gentle traction 
it was readily delivered. The feet were then taken with the 
left hand, the body drawn over to the patient's right and 
dropped downwards. With the right hand the anterior arm 
was sought. It was found extended and the right hand was 
pushed up over the anterior shoulder. With the fingers then 
along the right humerus the arm was flexed downwards across 
the baby's chest and delivered. The baby was quickly 
placed across the right forearm and the left hand grasped the 
baby at the neck. Combined with traction downward and 
suprapubic pressure as already described in the breech cases 
the head was extracted. As soon as the mouth was out of 
the vulva the remainder of the delivery was done slowly in 
order not to obtain serious lacerations of the perineum. 
Before the head was delivered the baby gave a few gasps. 
When delivered the cord was felt and it was not pulsating. 
The baby's heart was beating regularly and almost at once 
it began to breathe. The cord was clamped and cut at 
once. The baby soon cried vigorously. It moved its arms 
and legs normally and there was no apparent trauma 
done. The baby was given to one of the friends to look after. 
The placenta came away normally on the sixth contraction 



2l6 CASE HISTORIES IN OBSTETRICS. 

and was intact with all the membranes. A clean pair of 
gloves was then put on and the interior of the uterus explored. 
No rupture was found and no severe tear of the cervix. An 
intra-uterine douche of sterile water was given and it came 
back clear. Ergot was given intramuscularly. The patient 
was cleaned up and a sterile pad put over the vulva. One- 
half hour after the delivery was completed the patient's pulse 
was 72 and she was nearly out of ether. The baby weighed 
9I pounds. Six hours after the delivery the temperature was 
98.2° and pulse 62. Normal amount of flowing and the fundus 
was firm. She made an excellent convalescence. The tem- 
perature on the night of the second day rose to 99.2° and the 
pulse was 68. She was discharged on the twelfth day. 
Temperature normal and pulse 74. She had been up and 
about her home for the past three days. The baby was in 
excellent condition, nursing well and apparently gaining. 



PROLAPSED CORD. 217 

Case 33. Prolapsed Cord. Low Forceps. Lateral 
Position. December 23. Patient presents herself at the 
office to-day saying she is pregnant. She has skipped two 
periods. Her menstruation began at 13 years of age and it 
comes every twenty-five days. She never has any pain with 
her periods. She has never had any illness. She was married 
three months ago. The last normal menstruation was October 
30th. Vaginal examination: — slight increase of secretion. 
No secretion in the urethra. Cervix is soft. Uterus is dis- 
tinctly enlarged. Normal position and freely movable. 
Pregnancy is probable. Hygiene of pregnancy was gone over 
with her and she was asked to report at the office once a 
month. If she is pregnant she will be due for delivery about 
the 7th of August. 

She was pregnant at the time this note was made. Her 
pregnancy was perfectly normal and at no time was the blood 
pressure over 120 mm. of Hg. Urinary examinations all 
were normal. 

June 26. Pelvis measured to-day shows crests 28 cm., 
spines 25 cm., external conjugate 20.5 cm. Palpation shows 
at the present time a small baby. Head is well in the pelvis. 
Fetal heart is in the left lower quadrant. Definite fetal 
motion is felt on the right. Vaginal examination shows 
cervix flush with the vaginal vault. Os uteri not dilated. 
Biparietal diameter of the head is through the brim. Prom- 
ontory cannot be reached. Contour of the pelvis normal. 
Ischial spines not felt. Coccyx normal. Outlet is normal. 

Finding the head down so low in the pelvis with the cervix 
soft, and entirely taken up made me go over again very care- 
fully her menstrual history and the possibility of her becom- 
ing pregnant earlier than at first thought. From careful 
calculation and intimate history she probably will not be 
delivered before the first week in August. 

July 15. She was seen to-day by an assistant and was 
found in excellent condition. Urine examination normal. 
His findings corroborated my previous ones. 

July 31. Telephone from her husband to-night saying 
that the waters had begun to come away. An assistant was 
at once sent to her as I was out of town. At 1 1 p.m. I saw her 



2l8 CASE HISTORIES IN OBSTETRICS. 

and found she had had no pains but was dribbling away a 
small amount of liquor. Palpation showed a left posterior 
position. Anterior shoulder is well forward. Small baby. 
Fetal heart is in the right lower quadrant 132 to the minute. 
Patient's pulse 60. Temperature normal. A nurse was at 
once secured and the patient kept in bed. She was shaved 
but an enema was not given her. Orders given to the nurse : — 
to follow the fetal heart and report any alterations and report 
any pains. Temperature and pulse to be recorded three 
times a day. 

August I. No pains or contractions. Small amount of 
liquor still dribbling away. Fetal heart remains regular, and 
has not varied more than ten beats since the first observation. 

August 2. Palpation this afternoon showed still plenty 
of waters in the uterus. Uterus not tender or tight about the 
baby. Fetal heart has been regular all day varying only 
from 132-136. At four p.m. nurse noticed a few contractions. 
Fetal heart remained good, 128-134 as recorded by the nurse. 
At II P.M. patient was awakened by a few slight pains. At 
ten minutes of twelve a sudden change in the character of the 
pains occurred and they began coming every two minutes 
and the patient had an inclination to bear down with each 
pain. The nurse at once telephoned for me and I went to the 
patient at once arriving at 12:45 a.m. August 3rd. She was 
in very active labor. Fetal heart was regular but was not 
counted because she was in such active labor. I decided to 
examine her at once. At one o'clock I found the head very 
low, and what for a moment I thought to be unruptured 
membranes presenting. The head was just within the in- 
troitus. Feeling what I thought were the membranes my 
finger at once hooked about a prolapsed pulsating cord at 
the vulva. A loop of cord six inches long at once came out- 
side the vagina. My first inclination was to urge the patient 
to bear down as strongly as possible to see if she could push 
the head down so that I could expel it by pressure from be- 
hind the anus or by a finger in the rectum. At the first strain- 
ing effort she made, the cord stopped pulsating. I then told 
her to stop bearing down and the nurse who had already put 
the instruments on to boil was told to bring them to the room 



PROLAPSED CORD. 219 

at once. As the cord stopped pulsating I thrust my right 
hand into the vagina and pushed the head up off the perineal 
floor to give the cord an opportunity to pulsate. The mo- 
ment the cord began to pulsate I ceased pushing up the head 
but kept my hand in the vagina with a finger on the cord 
which now began to pulsate regularly. The patient had had 
no ether when I thrust my hand into the vagina but as soon 
as possible she was given it and made as comfortable as pos- 
sible. While waiting for the instruments it was seen that the 
perineum was already torn. The cord remained pulsating. 
The patient was lying in the left lateral position. There was 
no time to turn her to the dorsal position. The instruments 
were now at hand. The nurse forced the ether as rapidly as 
possible and the husband was told to raise the right leg. As 
the patient was going under ether she was told to bear down 
as much as possible. The head at once came down again on- 
to the perineum. The left blade, the lower, with the patient 
lying on the left side, was rapidly placed quickly followed by 
the upper blade. No attempt to push back the loop of cord 
was made. The cord was not pulsating when the forceps 
were put on. Masses of meconium appeared at the vulva. 
The head was at once pulled through the perineum and the 
body delivered. The baby was pallid and without tone. Cord 
was not pulsating. Cord was clamped at once and cut. The 
baby was drained and put in warm water. The heart was 
beating very slowly and as the baby was put into hot water 
for resuscitation it gave a gasp. From then on it steadily 
improved and soon began to cry lustily. After some minutes 
the baby became of good color and its muscular tone steadily 
improved. A great amount of mucus was present and several 
times the baby was drained. She was then carefully done up 
in a blanket with a sterile dressing over the cord, and a hot- 
water bottle put nearby. 

The patient was now out of ether, in excellent condition. 
Uterus was contracting well and there was no bleeding. In- 
spection of the perineum showed an extensive tear. I now 
waited until the assistant, who had been sent for, came. 
While waiting for him to arrive preparations for repair of the 
perineum were completed. Before he arrived the placenta 



220 CASE HISTORIES IN OBSTETRICS. 

came away intact without all the membranes. There was 
no bleeding and therefore there was no attempt made to 
remove them from the uterus. On the assistant's arrival the 
patient was etherized and the legs held in moderate lithotomy 
position. Examination of the perineum after thorough 
cleansing of the introitus with 70% alcohol and wiping away 
the meconium showed a second-degree tear to be present with 
a deep laceration on the patient's right. The internal tear 
was at once repaired with three chromic catgut sutures No. 2 
placed so as to include the depth of the tear. These three 
sutures brought the internal tear into excellent approxima- 
tion. The external tear was closed by three silkworm-gut 
sutures. The patient was put back to bed in excellent con- 
dition, pulse 80, uterus well contracted and no bleeding. 

The baby still continued to be choked with mucus and 
needed constant watching and another nurse was sent for. 
The baby breathed well and a quick examination of the lungs 
showed them to be expanded. Orders as follows, were left 
for the baby : — To oil it quickly in a room warmed to 80° F. 
Not to wash it. To dress the cord, put on the band but not 
to dress or handle the baby. To wrap it in a soft blanket. To 
keep the room at 70° and the crib at 80°. Sterile water in 
dram doses as needed. A modified milk, 2.00% fat, 6.00% 
sugar, 1.00% proteid was at once ordered for the baby, four 
drams every four hours. 

August 5. Is making an excellent convalescence. Tem- 
perature this afternoon 99.8°, pulse 70. Uterus involuting 
very fast. Lochia normal. Perineum shows no edema and 
there is no tenderness present. Milk is coming into the 
breasts and the baby is nursing well every two hours. The 
baby seems perfectly normal in all respects. It weighed 
to-day six pounds eight ounces. 

August 7. Temperature 98.8°. Pulse 70. Baby is gain- 
ing two to four ounces a day. A strip of membrane was 
found on the pad to-day. Lochia normal. 

August 8. About eleven this morning patient complained 
of pain in the left breast and at noontime had a severe chill 
lasting for twenty minutes and the temperature went to 
104.5°, pulse 100. She is complaining of a severe headache 



PROLAPSED CORD. 221 

and pains all over her body. Examination of the breast shows 
a definite flush over the inner lower quadrant, radiating out 
from the nipple. The whole breast is exquisitely tender to 
the touch. No definite lump is determined. Right breast 
negative. Chest is negative. Abdomen is negative. Peri- 
neum is not tender and looks well. The baby was at once 
taken off this breast. Ice-bags were put on the breast. 
Aspirin gr. x was given for her headache. The baby was 
put on a modified milk, the same formula as above noted, one 
ounce at every other feeding. 

August 9. Breast is very tender, full and hard. Tem- 
perature this morning 99°, pulse 90. Four bulbfuls of milk 
drawn off with the breast pump. Pulse to-night 94, tempera- 
ture 100.8°. The pulse has not dropped as hoped. 

August 10. At eight- thirty this morning the patient had 
another chill. Temperature at eight was recorded as 99.4°, 
pulse 80. The nurse says that the patient complains only 
of the left breast. I saw her within an hour. Temperature 
103.8°, pulse 100. She does not look sick but complains of 
the aching shooting pains in the left breast now more marked 
in the upper outer quadrant than in the lower inner one. 
She has a slight headache and her legs ache. Examination 
of the breast shows it to be very full but not exquisitely tender 
at any point. Nothing definite made out in the upper outer 
quadrant. Abdomen is negative as is also the chest. The 
condition of the breast does not seem to be sufficient to cause 
the present temperature and rise in pulse. She was placed 
across the bed in moderate lithotomy position and the peri- 
neum inspected and palpated. There was no tenderness 
present. The external stitches have cut slightly and were 
now removed. Bivalve speculum inserted into the vagina. 
Cervix shows a slight bilateral tear to be present and from the 
OS is coming a light brownish discharge. The vaults are 
smooth and normal in character. The tear on the right 
perineum is evident but is not tender to palpation. The left 
wall of the pelvis is normal. One of the catgut sutures was 
picked up with a forceps and about it a drop of brownish 
di'^^harge was seen. Wiped away with gauze sponge and it 
was found to have a foul odor. Suture removed and the 



222 CASE HISTORIES IN OBSTETRICS. 

tissues separated with the gloved finger. Surrounding this 
suture was a definite necrotic area and the tissues about this 
area separated more readily than tissue healing eight days 
normally should. Cavity wiped out with gauze soaked in 
70% alcohol and then packed with dry sterile gauze. 

Ice is to be continued to the breast. The patient does not 
look sick but she is not eating well and is sleeping poorly. 
Bowels are moving well. Temperature to-night 103°. Pulse 
100. 

August II. Temperature 101°, pulse 95, this morning. 
Slept well last night. The whole breast is less full and very 
much less tender. There now is a definite lump felt in the 
inner lower quadrant the size of a hen's egg. The ice-bag has 
been kept on the breast continuously. Gauze packing re- 
moved from the perineum. The cavity is dirty looking but 
no point of tenderness is found. Cavity wiped out and then 
repacked with a 10% iodoform wick. Except for the breast 
condition and for the perineum the physical examination is 
absolutely negative. The perineal wound is draining but 
little. The breast is much improved. I can see no reason 
why the temperature should not drop. The patient's pulse 
has never been over 105 and for that reason I do not regard 
her as seriously sick. 

Temperature to-night 103.4°, pulse 100. Though the 
temperature is up to-night higher than at any time except 
immediately after the first chill, her pulse has not corre- 
spondingly risen. 

August 12. Temperature this morning 98.6°, pulse 70. 
An excellent night. During the night she began to complain 
that the ice-bags made her chilly and the nurse telephoned 
for permission to remove them. It was allowed. This 
morning there is practically no tenderness in the breast. 
The perineum is discharging profusely and the odor is very 
foul. Packing removed and the cavity is much cleaner. 
Repacked with iodoform gauze wick. The baby was put 
to the breast but refused the nipple absolutely. Breast 
pump drew off only half a bulbful of milk. Baby is now to 
be put to this breast every other feeding in order to stimulate 
the breast. Temperature to-night 98.8°, pulse 76. 



PROLAPSED CORD. 223 

August 13. An excellent night. Temperature this morn- 
ing 96.7°, pulse 76. No tenderness in the breast. Profuse 
discharge from the perineum but without bad odor. Packing 
taken out. Cavity shows red granulations which readily 
bleed. Cavity repacked with dry sterile gauze. The baby 
is doing well on the right breast supplemented by the modified 
milk. There is no change in the feel of the left breast. 

August 14. The six-inch Bier bell put on the left breast 
to-day for five-minute periods every four hours (page 396). 
The baby still refuses this left nipple. With the breast pump 
a small amount of milk was withdrawn. 

The cavity in the perineum is much smaller. Repacked 
with small amount of dry gauze. 

Temperature and pulse normal all day. 

August 15. Breast to-day is much fuller and milk can be 
expressed from the nipple. Baby this afternoon nursed well 
from it and by weighing before and after nursing was found 
to have obtained one ounce. Bier bell is continued. Peri- 
neum dressed and the cavity is rapidly closing in. 

August 17. The left breast is secreting more and more. 
The baby is satisfied on it except for the long night interval. 
Perineum is rapidly healing. 

August 19. Wick in the perineum left out to-day, very 
slight amount of discharge. Patient is in excellent condition 
and the baby is to have no more modified milk. Bier bell 
is to be continued for a few days more. 

August 22. Perineum is practically healed. Tempera- 
ture remains normal. Pulse 70. Plenty of milk. Baby is 
satisfied now on the breast. Bier bells stopped. Is to get 
out of bed to-morrow and gradually walk about her room. 

August 29. No discharge from the vagina. Has absolute- 
ly no discomfort from the perineum. Feeling well in every 
respect and walking about as she wishes on her bedroom floor. 

September 6. Has slowly resumed her usual duties and 
seems perfectly well. Vaginal examination to-day shows no 
bulging of the anterior or posterior wall on straining. The 
perineal tear has granulated up well and is solidly healed. 
Uterus well involuted. Normal position. Freely movable. 
Not tender. Nothing felt on the sides. Feels like a slight 



224 CASE HISTORIES IN OBSTETRICS. 

bilateral tear of the cervix. Inspection shows a slight bi- 
lateral tear of the cervix with slight erosion. The baby 
has done consistently well, is satisfied on the breast and is 
gaining steadily. Patient discharged. 



Summary of Prolapsed Cord. 

There are two fundamental causes for the occurrence of a 
prolapsed cord; first, the presenting part does not snugly fit 
the inlet of the pelvis, and second, there must be a sufficient 
amount of liquor present to sweep down the cord when the 
membranes rupture. The distinction between a prolapsed 
and a presenting cord is simply whether the membranes are 
ruptured or not. If they are, the cord is called prolapsed. 
The distinction is largely an academic one for the treatment 
of both conditions is practically the same. It is true the 
danger to the baby while the cord is a presenting one is less 
than when it is a prolapsed one but the danger in either case 
is real. Case i6 gave an irregular fetal heart some days 
before labor began, but the membranes did not rupture early 
and on vaginal examination no cord was felt. When I came 
to deliver her by forceps I found a cord beside the head, not 
truly prolapsed, yet being pressed upon intermittently as 
shown by the irregularity of the fetal heart. This type of 
prolapse of the cord has been called ''occult.'* The danger 
to the baby in this form is not as great as when the cord is in 
front of the presenting part. In this occult type the danger 
is that when the membranes rupture the cord will still further 
come down and become a completely prolapsed one. Again, 
it is in these cases very easy to press upon the cord by the 
forceps if an operative delivery is undertaken. For this 
reason, as I have already said, the fetal heart must be listened 
to as soon as the forceps are locked in every forceps delivery. 

In Case 31 the manipulations in determining the position of 
the fetus brought down a loop of cord which already was low. 
In attempting to replace this loop another one came down 
and then the cord was felt twice about the neck. This was 
probably the reason the head did not engage because complete 
flexion was thus interfered with. 



PROLAPSED CORD. 225 

Replacement of the cord here failed and as the patient was 
under ether and about to be delivered for other reasons the 
problem here resolved itself into how best to deliver her. 
The only contra-indication for version was the fact that the 
membranes had been ruptured some hours. The risk of 
pinching the cord by the forceps blades, had forceps been 
attempted, far outweighed the danger of doing a version and 
therefore a version was done. The author has had poor 
success in attempting to replace the cord with the aid of the 
catheter and stylet. (For detailed accounts of this method 
consult any of the obstetrical textbooks.) 

Another way recommended of managing these cases when 
the cord prolapses is to pass the hand up into the vagina and 
uterus, carrying up the cord with the hand. The cord is 
tucked safely away and the head drawn down into the pelvis 
by forceps if necessary and the case then left to nature. To 
the author's mind there cannot be a worse way to manage 
such a case. Ether in the large majority of cases must be 
given to do this and if one can carry the hand up into the 
uterus for this, surely with but little more dilatation the 
cervix can be dilated enough to deliver the baby which is 
in utero. 

A physician must not subject the mother to too great a risk 
for the possible life of the child, but the rights of the child to 
live with due regard to the mother's future health must in 
every case be borne in mind. This was shown well in Case 33. 
The child was alive as shown by the pulsations in the cord, 
but as soon as the patient strained down the pulsations ceased. 
I had to disregard the amount of pain I caused her for the 
sake of her child and therefore thrust my whole hand into 
the vagina in order to push up the head. In so doing I tore 
the perineum. The head was not pushed entirely out of the 
pelvis and the question came to mind whether to apply the 
forceps or to do a version and I chose the former for I felt 
the danger of sepsis was less from this than from a version. 
Especially so as the cervix had retracted over the head and 
I should not need to go inside the uterus. Forceps in the 
lateral position unquestionably saved valuable time in this 
case. The perineum was disregarded and the head quickly 



226 CASE HISTORIES IN OBSTETRICS. 

pulled through it. An intact perineum meant a dead baby 
and there was no question what to do. 

In this case, Case 33, postural treatment would have been 
of no avail for the head was in the pelvis and the uterus was 
contracting. In Case 32, the externe did exactly the proper 
thing in placing the woman in the knee-chest position and 
keeping her there until help came to him. This case em- 
phasizes the reason why every patient should be told to go 
to bed the moment the waters break and stay there until her 
physician arrives. To a physician it should conclusively 
prove that he must go to a patient the moment he is informed 
that such an accident has happened. If one knows that the 
head is in the pelvis when the waters break, the chances of a 
cord prolapsing are very slight and the necessity for making 
a vaginal examination is not present provided the fetal heart 
is heard and is regular. But if the presenting part is not in 
the pelvis, a vaginal examination ought then without question 
to be made in order to rule out absolutely a prolapse of the 
cord. 

Case 33 went forty-eight hours after rupture of the mem- 
branes before she started up in labor. All this time the fetal 
heart was watched and at no time was it irregular nor did its 
rate vary. The head I knew to be down low in the pelvis and 
therefore there was no indication to make a vaginal exami- 
nation and yet the cord was prolapsed for how long a time no 
one knew. Had a vaginal examination not been made during 
labor the outcome of the case would have been far different. 
An occasional vaginal examination made with the care already 
described does no harm and may as in this case tell of 
threatening danger. 

Prolapsed cords are more frequent in breech presentations, 
especially footling or double footlings, than in vertex presen- 
tations, because the presenting part does not so accurately 
fill the inlet. The same holds true with transverse presenta- 
tions and in this condition the physician must ever be on the 
alert for this accident. Careful watching of the fetal heart 
and a vaginal examination immediately after the rupture of 
the membranes will do much to reduce the infant mortality 
from prolapsed cords. 



PROLAPSED CORD. 227 

With a high presenting part a version, unless there is some 
definite contra-indication, is the operation of election when a 
pulsating prolapsed cord is found. It is unusual to find a 
prolapsed cord when the presenting part is low; when dis- 
covered, forceps usually will be elected to extract the baby, 
and this is especially true if the patient is a multipara, where 
the resistance of the soft parts may quickly be overcome. 
No matter which operation you elect, forceps or version, be 
certain that the cervix is fully dilated before you attempt to 
deliver, for a delay caused by the cervix may mean the death 
of the baby. If the cord is not pulsating and is flaccid when 
the physician first sees it there is no indication to operate. 
By the time he can get his hands prepared there would be no 
hope of obtaining a live baby and it is unjustifiable to subject 
the woman to an operative delivery and risk of sepsis from 
a hurried operation when it is already known that the baby 
is dead. 



SECTION VIII. 
VERSION. 

Case 34. Flat Pelvis. Elective Version. Post- 
partum Hemorrhage. This case was seen in consultation 
July 15th. Telephone message from the physician in charge 
at nine o'clock in the evening stated that he had in labor a 
patient with a contracted pelvis and that there was a question 
of performing a Caesarean section. I saw the patient at 
ten P.M. and the following history was obtained. She had 
had three full-term children before this pregnancy. All were 
lost after hard operative deliveries. None of the children 
had been weighed and there is no clear story of what was done 
on the first two deliveries. On the third the patient was 
allowed to go into labor for four days and then a destructive 
operation was performed. ' 

The present labor started at 3 a.m., July 15th. The patient 
did not send for her physician until half past two of the same 
afternoon when the membranes ruptured. When her physi- 
cian saw her first she was in good labor with pains coming 
every ten minutes. He apparently made no examination, 
determining to let her continue labor. At eight o'clock he 
examined her and found her, he said, half dilated but the 
head could not be reached. He then called a local surgeon in 
consultation with the intention of having him do a Caesarean 
section. The surgeon said he was busy but would see the 
patient in the morning and then would do the section. 

The patient at ten p.m. was having pains every five min- 
utes. Palpation showed a fair-sized baby lying in a left 
position. The head was freely movable at the brim. The 
uterus was soft between the pains, but slightly tender. 
There was a marked separation of the recti muscles. The 
whole abdomen was very pendulous. The fetal heart was 
heard in the lower left quadrant, 130 to the minute and 
regular. External pelvimetry gave crests 27.5 cm., spines 

229 



230 CASE HISTORIES IN OBSTETRICS. 

24.5 cm., external conjugate 18.5 cm. Patient's pulse 100. 
Temperature 99°. Vaginal examination showed the severe 
tears of the previous deliveries. The whole hand could be 
inserted into the vagina without ether. The os uteri was half 
dilated and cervix was thick. My closed fist could with diffi- 
culty be passed between the promontory and the symphysis. 

The physician asked me to talk with the surgeon in re- 
gard to doing a section the next morning. I flatly refused 
to, saying I felt if a Csesarean should be done under these 
circumstances it would be nothing short of malpractice. I 
advised a manual dilatation and an elective version because 
of the flat pelvis and the pendulous abdomen. I said I 
thought a living child could be obtained. By this time, 
eleven o'clock, the patient had been in labor some twenty 
hours without making progress and the membranes had been 
ruptured about nine and I again insisted that a Caesarean 
was absolutely contra-indicated. 

After much arguing my advice was finally taken and we 
completed as quickly as possible the preparations for delivery. 

The kitchen table was brought to the patient's room and 
when all was ready she was placed upon it and etherized. 
There was a good supply of hot corrosive solution 1-3000 
made ready and a pail of hot water was at hand in order to 
resuscitate the baby. The usual instruments were on a 
nearby table. The patient's legs were held by two friends. 
When she was under the ether she was carefully scrubbed up 
by the assistant I had taken with me. No douche was given. 
The vulva and vagina were thoroughly cleaned with 70% 
alcohol. She was then catheterized and some four ounces 
of urine obtained. The perineum needed but little dilata- 
tion. The cervix dilated readily and when fully dilated, the 
cervical ring was felt intact. The closed fist was then brought 
through the cervix slowly three times and there was no 
resistance. No contraction ring was felt. The closed fist 
could be brought through between the promontory and 
symphysis without great difficulty but with the thumb out 
it was a very tight fit. The position was determined to be 
O. L. A. My assistant gave me fundal resistance as the left 
hand was passed into the uterus along the child's abdomen; 



VERSION. 231 

without difficulty, a foot was found. I then told the assistant 
that the head would go up on the left to the fundus. Trac- 
tion downward was made on the seized foot and it was seen 
to be the right and the anterior leg. A long loop of cord came 
down and it was at once seen to be between the legs. It was 
slipped over the leg without difficulty. 

With traction downward on the leg the posterior buttock 
at once came to the perineum and was delivered without diffi- 
culty by a finger in the groin. The left arm was the perineal 
and was not extended and was delivered with ease. 

The buttocks had come down in the right oblique diameter 
and the shoulders were kept in this diameter. In order to 
obtain more room and because the right arm was extended 
the baby's body was turned to my right, making this, the 
right arm, now the perineal. With my right hand I went up 
over the shoulders along the extended arm and gradually 
was able to bring down and to flex out the arm across 
the face. The shoulders were then kept in line with the 
antero-posterior diameter of the pelvis with the hope that 
the bitemporal diameter of the head would come through 
in the antero-posterior diameter of the pelvis. With 
traction downward on the body combined with excellent 
suprapubic pressure from my assistant the head descended 
through the brim and as it came to the perineum the occiput 
was rotated forward and then readily delivered. There was 
at once a severe hemorrhage. The baby cried at once, 
its cord was clamped and cut and it was given to the 
assistant. 

The uterus was relaxed and the bleeding was profuse. The 
gloved hand was at once washed off in 70% alcohol and 
passed into the uterus. The lower half of the placenta was 
found detached and it was at once manually removed. It 
was, at this time, noticed that the cervical ring was intact and 
the uterus was not ruptured. Inspection of the placenta 
showed it to be intact and that all the membranes were 
probably present. The patient still was bleeding but not as 
freely; the uterus did not contract. A five-yard packing 
strip was at once soaked in 70% alcohol and an end carried 
up into the uterus. The uterus was held from above by the 



232 CASE HISTORIES IN OBSTETRICS. 

physician-in-charge. The uterus was firmly packed as was 
also the vagina. About four yards were used. The bleeding 
stopped. By this time ergot intramuscularly had been given 
twice. The uterus was held firmly from above and ice was 
put to the fundus. A pad was put on the vulva and the 
patient was at once put back to bed with a pulse of 140 but 
looking in fair condition. There was no attempt made to 
repair the fresh slight tear of the perineum. She soon came 
out of ether and began throwing herself about. She was 
given one-sixth of morphia subcutaneously and became quiet. 
The uterus was held constantly and an hour after delivery 
was staying well contracted and there was no bleeding. 
Pulse came down to 120 and was of good volume. 

Examination of the baby showed that no limbs were broken, 
no paralysis was present. Cried well and apparently was 
in good condition. It was not weighed or washed, simply 
oiled and done up in absorbent cotton and kept warm. 
Estimated weight seven pounds. We left at three a.m. both 
patients in good condition. 

July 16. This afternoon I went out to remove the packing. 
The uterus is hard and but slightly tender. Temperature 
is 100°. Pulse 100. Of excellent volume. She has not 
vomited and has taken plenty of nourishment. She has not 
voided urine. She was put across the bed and the packing 
slowly removed. The packing was not entirely soaked 
through with blood. There was no bleeding. She was then 
given an intra-uterine douche of two quarts of sterile salt 
solution followed by one pint of 70% alcohol. This latter 
was given very slowly. It was now seen that the perineum 
was torn only slightly more than before and I left it to 
granulate. 

July 18. Physician reports the patient's temperature as 
100.4°. Pulse 90. She has voided regularly and the bowels 
have moved. Breasts are engorged but the baby is nursing 
them out fairly well. 

August I. Telephoned to-day to the physician-in-charge 
and he says the patient has made a good convalescence. She 
ran no temperature. Is now up and about the house and 
nursing the baby. 



VERSION. 233 

Management of a Post-Partum Hemorrhage. 

The above case is a typical example of a severe post-partum 
hemorrhage. Some writer has said that a physician's skill 
in obstetrics may be measured by the rarity of post-partum 
hemorrhages which occur in his practice. Unquestionably 
this is true for the watchful painstaking man scarcely ever 
sees bleeding which may be called a hemorrhage. It must 
not, however, be inferred from this that in every hemorrhage 
the physician is to be blamed, for that is far from the truth. 
The physician, who in normal obstetrics has a half dozen 
more or less severe hemorrhages a year is without doubt doing 
poor obstetrics and should go carefully over his technique for 
there is a grave error somewhere in his work. 

Hemorrhage is likely to occur in cases where there is a slow, 
drawn-out labor without progress or where there is marked 
over-distention of the uterus as in the case of twins (already 
mentioned), or in hydramnios, either acute or of gradual 
onset. It is seen when the labor is hard and no progress is 
made or where the labor is precipitate. In a word it may 
occur whenever the mechanism of normal labor is interfered 
with in any way. 

In Case 34 the direct cause of this hemorrhage was the 
partial separation of the placenta allowing the sinuses to 
bleed freely. The type of hemorrhage was primary in that it 
occurred at once after delivery of the child (it also would 
have been called primary had it followed at once the delivery 
of the placenta), and it was external because it was seen. 
Opposed to these two divisions are internal or concealed and 
secondary post-partum hemorrhage. In internal the blood 
distends the uterine cavity; its exit is stopped either by the 
contracted os uteri or by the placenta. In this type of 
hemorrhage the uterus is never properly held and if the hand 
is placed on the fundus a resilient tumor is felt which, if 
pressed upon firmly, quickly becomes smaller, coincident 
with the expulsion from the vagina of many large blood clots 
and much free blood, the amount depending, of course, upon 
how long the hemorrhage has been going on, upon how care- 
less and inefficient the nurse and physician may be. Second- 
ary post-partum hemorrhage is practically always due to the 



234 CASE HISTORIES IN OBSTETRICS. 

retention of some of the products of conception. It is for 
this reason that the inspection of the placenta becomes of 
such importance. A cotyledon, portions of the amniotic sac 
or a placenta succenturiata may be left behind. In Cases 
12 and 33 it was known that some of the membranes were 
retained but as the uterus remained well contracted and there 
was no bleeding there was no indication to explore the uterus. 
If the uterus acts well and there is no bleeding I believe it is 
better obstetrics not to explore the uterus even when it is 
known that there is something left behind. Only under one 
condition do I enter the uterus, even when there is no bleeding 
and that is when I am positive there is a placenta succen- 
turiata and the patient is where immediate aid cannot be 
given her should bleeding occur. The danger of sepsis from 
entering the uterus in such condition far outweighs the 
probability of serious hemorrhage. It should be needless to 
add that one*s aseptic technique in entering the uterus in 
these conditions must be perfect. 

A placenta succenturiata is an anomalous development of 
placental tissue in the membranes. Blood vessels always 
lead to this placental tissue from the main body of the pla- 
centa. If on inspection of the placenta and membranes, blood 
vessels are seen running off from the placenta on the mem- 
branes and the broken ends of the vessels are seen, this is 
conclusive evidence that a placenta succenturiata is present. 

The fundamental treatment of post-partum hemorrhage is 
prevention. This has already been covered in the manage- 
ment of normal labor. A badly managed third stage is more 
often responsible for hemorrhage than any other one cause. 
Again must it be insisted upon that a hand must be kept on 
the fundus from the expulsion of the child until after the 
completion of the third stage, when the uterus is firmly and 
permanently contracted. 

One must be prepared to meet this emergency in every 
delivery and for that reason the instruments, salt solution, 
gauze and ergot must be ready at each delivery. In Case 34 
the outpouring of blood was tremendous. One who has never 
seen a serious post-partum hemorrhage can scarcely realize 
what a flooding occurs. Had the preparations for combating 



VERSION. 235 

hemorrhage not been ready, the life of this patient would have 
been seriously jeopardized. Even if one has everything ready, 
occasionally the bleeding will be so rapid that temporary 
checking of the bleeding must be obtained at once. This can 
be done as in Case 38 by thrusting the gloved hand into the 
vagina, placing the four fingers and thumb about the cervical 
ring in the culs-de-sac and with the other hand about the 
fundus squeeze the uterus tightly on itself. In Case 38 this 
was sufficient and quickly the uterus contracted and the 
bleeding grew less. Another means is to thrust the whole 
hand into the uterus, clench the fist and then give firm counter 
pressure on the uterus through the abdominal wall. The 
objection to this method is the danger of infection. This 
objection, however, is true of all means we have of stopping a 
severe hemorrhage. 

The commonest method in vogue to-day to stop a post- 
partum hemorrhage is to give a copious hot, 115°, sterile 
douche or one of corrosive sublimate 1-10,000. In Case 30 
this was used and the uterus at once began to contract. In 
Case 34 the outpouring was tremendous and I packed the 
uterus at once. It is in such a case that the value of the five 
yard piece of sterile gauze is shown. Never pack the uterus 
with small pieces of gauze for the danger of leaving one 
behind is great and also the difficulty in removing them is 
much greater than if but one piece is used. How much to 
pack into the uterus experience alone will tell. The point 
to be remembered is that over distention of the already poorly 
acting uterine muscle must not occur, yet the entire cavity 
must be filled and also the vagina. It is a doubtful procedure 
to pack the vagina alone and not the uterus. To this state- 
ment there is one exception and that is when the uterus acts 
well and the bleeding is from the cervix or perineum. Then 
the vagina alone may be packed. 

In Case 34 the bleeding started from a partially separated 
placenta. Before any effective means can be used to check 
an hemorrhage the uterus must be empty. Either the placenta 
must be expelled by Crede^s method or it must be removed 
manually. Be sure that the placenta is intact with all the 
membranes, for if the membranes are left behind where the 



236 CASE HISTORIES IN OBSTETRICS. 

Uterus is already bleeding, more bleeding will undoubtedly 
follow. 

Coincident with the emptying of the uterus ergot should be 
given intramuscularly. Whether the extract from the pos- 
terior lobe of the pituitary body will prove more efficacious 
than ergot in making the uterus react, remains to be more 
fully investigated. I have given it many times with excellent 
results where the uterus was relaxing and a constant oozing 
taking place. Both preparations, pituitrin and hypophysin, 
are apparently reliable. They act much more quickly than 
ergot but their action is of much shorter duration and for 
that reason ergot also should be given. 

Gentle manipulation of the uterus together with ice to the 
fundus will in the milder degrees of hemorrhage prove suffi- 
cient, but in a true post-partum hemorrhage they are not to 
be relied upon except as aids to more efficient means. 

In very rare cases salt solution may have to be given intra- 
venously. Unless the physician who attempts this has had 
experience in doing this little operation, he had much better not 
try it for, simple as it seems, there are many pitfalls for the 
beginner. I almost never give salt solution under the breasts 
for post-partum hemorrhage, for I believe that if patients are 
in such a condition that they need it, it is better judgment 
to give it directly into a vein. Here it acts at once, while if 
it Is given under the breast there is an appreciable time before 
it is absorbed. If one wishes to give salt solution the rectum 
is always available, and it Is astonishing to see how much may 
be quickly absorbed in this way without disturbing the 
patient. 

A uterus that has been packed should be held firmly from 
above until it recovers its tone and remains hard. There 
can be no time limit to this holding. Gradually as the tone 
returns, the Intervals during which the uterus is not held may 
be increased, but at first this increase must be very slow. 

In the majority of cases the packing is left in the uterus 
about twelve hours; then it is removed. The patient is then 
given a douche of sterile water followed by a pint of 70% 
alcohol. In taking out the packing strict asepsis must be 
observed. The patient is put across the bed. The vulva 



VERSION. 237 

wiped off with 70% alcohol. The physician's hands are 
prepared as for a delivery and sterile gloves put on. A rat- 
tooth forceps seizes the presenting gauze and gradual traction 
is made on it until it all is removed. A bivalve speculum is 
inserted into the vagina and the os uteri brought into sight. 
The cervix is then wiped off with alcohol and an intra-uterine 
nozzle is passed directly into the uterus. The water must be 
running before the nozzle is inserted in the uterus. The 
bottom of the douche bag or can must be on a level with the 
bed, in other words the water must run without force. After 
the uterus is washed out with two quarts of sterile water, a 
pint of 70% alcohol is allowed to run in very slowly, and all 
that will is allowed to remain in the uterus and vagina. The 
nozzle is removed and a sterile pad is put in place and the 
patient turned about and made comfortable in bed. 

As yet there have not been many cases reported of direct 
transfusion of blood in cases of severe post-partum hemor- 
rhages. There are, especially in hospital work, many cases 
where transfusion might be done and brilliant results 
obtained. Since the technique of this procedure has been so 
materially simplified, without doubt more and more reports 
will appear of the successful results of transfusion. 

In the after care of a patient who has had a severe post- 
partum hemorrhage, food and rest are the two necessities. 
Small amounts of liquid nourishment must be given as soon 
as possible and repeated at frequent intervals. Then gradu- 
ally the food is increased until the patient is having a full 
nourishing diet. Morphia in small doses will give the re- 
quired rest. Generally there is no indication for the use of 
drugs. The liability of the patient to infection due to her 
lowered resistance is present in these cases and therefore the 
aseptic technique must be more rigid, if possible, than in 
normal cases. 



238 CASE HISTORIES IN OBSTETRICS. 

Case 35. Flat Pelvis. Elective Version. This pa- 
tient is the same as in Case 22. I knew nothing more of this 
woman until the following December, eleven months after 
the previous delivery took place. She entered the Boston 
Lying-in Hospital at 10:15 p.m. with the following story: 
She says she is at full term and that the pains began at one 
P.M. to-day. She sent for an externe at six o'clock and in 
the usual routine of the hospital the house officer saw her 
at eight. He then found the head lightly engaged, os fully 
dilated and large caput present. He noticed that the promon- 
tory was very prominent. The house officer at once reported 
the patient to the physician-in-charge of the out-patient 
department for the month and he advised that she be brought 
into the hospital at once because of her previous operative 
history. She refused to be brought in and only after con- 
siderable urging and much persuasion did she enter. She 
entered, as stated, at 10:15 p.m. As I was then at the 
hospital, the physician-in-charge of the out-patients asked me 
if I would see the case for him, which I did. Palpation of 
the abdomen showed a fair-sized baby lying in a left position, 
vertex presenting. Uterus was soft between the pains which 
were coming every five minutes lasting one-half to three- 
quarters of a minute. Uterus was not tender and the patient 
was in excellent condition. Pulse 100, temperature normal. 
I advised immediate delivery and my advice was accepted. 
I made no vaginal examination for an excellent house officer 
had reported her fully dilated two hours previously. I told 
the house officer that I should attempt at once a version 
because of the flat pelvis. She was prepared at once and 
immediately etherized. She was placed in moderate lithot- 
omy position. Under the usual aseptic precautions she 
was catheterized and the perineum thoroughly dilated. A 
large caput was felt; the head was movable above the brim, 
the position was O. L. A. The left hand was inserted into 
the vagina through the cervix and the head displaced. 
Good resistance was given at the fundus and the hand was 
pushed up into the uterus and the anterior leg seized. Ver- 
sion was then readily performed. Both arms were extended, 
but without great difficulty were freed. The shoulders came 



VERSION. 239 

down in the right oblique diameter, and were delivered. 
Traction was then made on the shoulders, which were held so 
that the bis-acromial diameter was in line with the antero- 
posterior diameter of the mother's pelvis, in the hope of 
bringing the head down in transverse diameter. With in- 
telligent suprapubic pressure, the head came down through 
the brim. The occiput then rotated forward into the antero- 
posterior diameter, and the head was delivered without 
difficulty. The mother stood the operation well and there 
was no abnormal amount of bleeding. The placenta was 
delivered intact with all the menbranes five minutes after 
the birth of the child. The perineum showed no fresh tears. 
The cervix was not examined as there was no marked amount 
of bleeding. She went off the table with a pulse of 72. She 
was given ergot intramuscularly and an intra-uterine douche 
of sterile water followed by alcohol 70%. Examination of the 
baby which weighed six pounds two ounces showed that it 
moved its left arm poorly and every time it was moved cried 
out in pain. The greatest point of tenderness, apparently, 
was over the external condyle. The elbow was put up in 
acute flexion and kept that way for five days. It was then 
taken down and the baby was allowed to move it gradually. 
Examination of the mother on the twelfth day showed the 
uterus fairly well involuted, normal in position and a bilateral 
cervical tear and a slight yellowish discharge present. The 
baby weighed six pounds nine ounces and was gaining. It 
moved both arms equally well. The patient was warned 
that if she again became pregnant to place herself in charge 
of the hospital early and not to wait until the last moment. 



240 



CASE HISTORIES IN OBSTETRICS. 



Case 36. Flat Pelvis. Elective Version. Forceps 
TO THE After-coming Head. The patient is the same 
as in the previous case. She applied for care early in 
her pregnancy and reported up to the ninth month. 
From then on we saw nothing of her until she entered 
the hospital at 4:45 p.m. November 22nd, two years after 
her last confinement. As I had already operated on this 
patient twice, the physician-in-charge of the hospital asked 
me if I would see her again. Palpation of the baby showed 
a very much larger baby than previously, and I strongly 
advised her to have a Csesarean section. This she abso- 
lutely refused, and as she refused I decided to let her go 
into labor until she was fully dilated and then to do a ver- 
sion as the operation of election. She was not examined 
vaginally because of the possibility that she might change 
her mind and a Csesarean section be done. Membranes 
ruptured, however, at 8:15. She was then examined vagi- 
nally, and it was found that the os uteri was fully dilated. 
Position, occiput left posterior. Fetal heart was 120 in the 
left lower quadrant. Uterus was acting well. Pains com- 
ing every four minutes, lasting one minute. The head was 
free above the brim, and was making no attempt to come 
into it. Patient was then etherized and placed in lithotomy 
position. The legs were held by nurses. With excellent 
resistance on the fundus I went up and seized the anterior 
leg. Brought it down readily. There was no difficulty 
with the version or extraction until I came to the extraction 
of the head. With one traction I could not gain anything 
and because of the marked increase in the size of the baby 
I put forceps at once to the after-coming head, and with the 
combined efforts of forceps to the after-coming head and 
suprapubic pressure I delivered the baby. The baby was 
asphyxiated but it was soon resuscitated. There was a deep 
cervical tear on the left, which bled profusely. I repaired 
this tear at once with two catgut sutures and the bleeding 
ceased. The placenta came away intact with all the mem- 
branes. Intra-uterine douche was given followed by 70% 
alcohol. Ergot intramuscularly. She went off the table with 
a pulse of 120. Weight of baby was seven pounds and five 



VERSION. 241 

ounces, one pound more than the previous baby. The pa- 
tient made an absolutely normal convalescence, but on 
December 4th developed a positive culture of diphtheria as 
did also the baby. She and the baby were then transferred 
to the South Department of the Boston City Hospital. The 
baby at that time weighed seven pounds and eleven ounces. 
A report from the hospital on December 29th said that both 
patients were discharged well on December 23rd. Vaginal 
examination of the patient just before she left the Lying- 
in Hospital showed the uterus still slightly enlarged. Nor- 
mal in position. Vaults were free. Marked cervical tear on 
the left running into the left vault. Excellent perineum. 



Summary of Indications for and Technique of Version. 

The four chief indications for performing a version are 
(i) prolapse of the pulsating umbilical cord, (2) malpositions 
of the fetus, especially transverse presentations, (3) hemor- 
rhage, consequent upon the pregnancy ; this includes placenta 
prsevia and accidental hemorrhage, (4) conditions of the 
pelvis, chiefly flat pelvis. To these four indications must be 
added the personal equation of the operator for unquestion- 
ably in the same type of cases one operator will elect a high 
forceps while another will choose a version as the operation 
of election. This personal equation in operating can never 
be eliminated, nor is it desirable that it should. Each expe- 
rienced operator must be guided by the results he knows he 
can obtain and not be tied down to any rule but the beginner 
should follow the rules laid down by the majority of expe- 
rienced operators until he has had sufficient experience to 
settle for himself each individual problem. Five of the 
preceding six cases are examples of the first and fourth indi- 
cations. The second and third indications are dealt with 
In other cases under transverse presentations and placenta 
praevias. I shall only discuss here the technique of per- 
forming version and applying forceps to the after-coming 
head, for the extraction has already been explained under 
breech delivery and extraction (pages 173-197). The prep- 
arations for the version are the same as for all operative 



242 CASE HISTORIES IN OBSTETRICS. 

deliveries. Remember, a version is not to be attempted 
except in grave emergencies unless your instruments includ- 
ing forceps are ready. Also a pail of hot water must be at 
hand to resuscitate the baby, for some degree of asphyxia is 
most common. As essential as it is in forceps deliveries to 
have the perineum and the cervix fully dilated, it is even 
more essential that these conditions be fulfilled when version 
is planned. More than once I have seen the after-coming 
head held up by the constricting cervix and delivery accom- 
plished only by much traction resulting in severe lacerations 
of the cervix and perineum. 

The patient is etherized to full surgical anesthesia before | 

any attempt to turn is made. While this is being accom- 
plished the patient is placed in the dorsal position, legs held 
by a leg holder or by assistants. Aseptic preparations com- 
pleted, the bladder is emptied without fail. Sterile towels and 
hot sterile water or corrosive solution 1-3000 are at hand. 
Then proceed to the dilatation. In the above cases the os 
uteri was fully dilated except in Case 31. Here the cervix 
was thin and dilated up very readily. Never fail to over- 
come the resistance of the cervix. It may seem as if time 
were wasted but be assured it is valuable time gained. This 
is seen in this case for there was no difficulty with the after- 
coming head. Determine the position of the fetus in utero 
accurately. The hand, the palm of which faces the baby's 
belly is the hand which is pushed up carefully into the uterus. 
In other words, in left positions the left hand, in right positions 
the right hand is used. Never start to push the hand up 
into the uterus unless you have strong resistance on the fun- 
dus. Once I did this without resistance in a placenta prsevia 
and tore badly the lower uterine segment. If you have not 
with you skilled help, choose the most intelligent person 
about and tell him or her what you want done. In pushing 
up the hand if you feel the uterus contract, stop where you 
are and make no attempt to go higher. When the contrac- 
tion has ceased, begin again the search for the foot. If the 
membranes are ruptured well and good. If they are not" 
they must be before the foot is seized. Objection has been 
raised to pushing the hand upwards between the amniotic 



VERSION. 243 

sac and the uterine wall because of the increased danger of 
infection. Again and again I have done this without any 
subsequent rise of temperature. The advantage of this is 
that your forearm acts as a cork and no liquor escapes until 
the version is begun. If you rupture the membranes before 
you go up for the foot, have your hand inside the cervix at 
least, so as to keep as much liquor as is possible within the 
uterus, for version then is much more readily performed. 
When the proper hand is within the cervix it should not be 
brought out of the vagina until the foot has been seized and 
brought down. Be sure you seize a foot and not bring down 
a hand. Almost every operator of any experience has made 
this mistake. The heel is the diagnostic point but other 
points help one settle whether it is the foot which is grasped 
or the hand. One can close the thumb over the palm in the 
hand and the fingers will grasp your fingers. 

Attempt to seize the anterior foot; this is best accom- 
plished by following up the anterior thoracic wall until you 
reach the flexed anterior thigh and then following down the 
thigh to the foot. The difficulty in getting the anterior foot 
generally lies in the operator feeling about aimlessly with 
the hope of meeting what may be a foot. Remember if you 
meet a small part in the uterus at once, the chances are that 
it is not a foot; the feet in a vertex presentation are prac- 
tically never within easy reach but always well up within 
the uterus. The foot found, grasp it by the heel, the in- 
dex finger over the heel, the middle finger in front over the 
dorsum of the foot. The thumb is then brought up on the 
opposite side. I practically never bring down both feet 
although there are many operators that always attempt to 
do so. 

As the operator starts traction downward on the leg, he 
tells his assistant which way the turning is to take place. 
The assistant then puts his hand beneath the vertex and 
pulls it gently upward towards the fundus. In some of the 
above cases this was of much aid in turning. If you are 
alone and you cannot start the version place a sterile towel 
over the abdomen and push the head up from the outside. 
Occasionally you may have to put a fillet (see page 360) 



244 CASE HISTORIES IN OBSTETRICS. 

on the foot and draw down on this, while with the other hand 
in the vagina you attempt to displace the head upwards. 

The difficulty in performing a version is usually in the 
starting of it. This overcome, and the head in the fundus, 
the remainder of the delivery is as in the extraction of the 
breech which has been fully described. The reason for seek- 
ing the anterior foot is that if the posterior is obtained the 
anterior buttock comes against the symphysis and retards 
the delivery. If the baby is small it makes no material 
difference but if it is large the delivery may be so delayed 
that the baby will be lost. If the posterior is brought down, 
then it must be rotated forward so as to make the posterior 
buttock the anterior. This is done by traction downward 
combined with rotation on the leg. 

In Case 32 after the delivery was completed I explored 
the interior of the uterus. There is a definite risk in doing 
this of infecting the patient and unless you have a freshly 
sterilized pair of gloves to put on it should not be done. But 
if the version is difficult, it gives much peace of mind to find 
by exploration the uterus intact, and should a rupture of the 
uterus have taken place, immediate treatment may be begun. 

Reference to Case 22 which is the same patient as Cases 
35 and 36 shows clearly the contra-indications for version. 
They are a tonic uterus, the presence of a tight contraction 
ring, and a uterus which is dry, that is, one where the liquor 
has drained away. Another contra-indication, but one 
which it should be unnecessary to call attention to, is exces- 
sive disproportion between the child and the pelvis. This 
contra-indication is of course true for any operative delivery 
by the vagina. The higher the contraction ring becomes, 
the thinner is the lower uterine segment and the more dan- 
gerous becomes any operative procedure. Forceps is less 
dangerous than a version under these conditions and if the 
baby is in poor shape or dead, a destructive operation should 
be done. One dislikes intensely to perform a destructive 
operation on a living child but if by the operation chosen 
death of the fetus follows and morbidity of the mother is 
great, then a destructive should be done to safeguard the 
mother. In Case 22 there was no possibility of performing a 



VERSION. 245 

pubiotomy as the patient absolutely forbade any ''cutting 
operation." Further, in this case pubiotomy would have 
been a doubtful procedure as the baby was in not too good 
condition, as shown by the fetal heart. 

The technique of forceps to the after-coming head is diffi- 
cult to describe. There are certain points that may be 
emphasized. The child's body and arms are in the way 
and to get them out of the way the simplest and best means 
is to take a sterile towel and wrap it quickly about the child. 
The towel should be first placed under the baby's thorax, 
the thorax resting in the middle of the towel. Then the 
ends are brought about the back first one end and then the 
other. Thus applied the towel holds the arms securely at 
the baby's sides and the ends of the towel do not get in the 
operator's way. The body is then drawn upward into as 
near a vertical position as is possible and the feet given to 
the nurse or anyone who is helping you to hold in this posi- 
tion. Care must be taken not to let your hands touch any- 
thing which is not sterile. The left blade of the forceps is 
at once grasped and the fingers of the right hand put into the 
vagina and the blade placed on the left of the mother's pelvis. 
The right blade is then placed opposite this first blade. The 
body being held up, the forceps must necessarily be put on a 
little differently than in the oncoming head. Here the 
handle of the forceps is first held nearly horizontal and to the 
opposite side of the patient to the name of the blade, i.e., 
if it is the left blade that is applied the blade is held well to 
the patient's right. The position of the right blade when the 
application is begun is just the opposite. Unnecessary time 
must not be taken to get a perfect application of the forceps. 
If the forceps lock easily and on the first traction do not 
slip, let well enough alone. Traction is made downward and 
backward or in the direction necessary according to the 
height of the after coming head. A word of warning must 
be given, — make absolutely certain that the forceps are 
placed within the cervix, never under any circumstances out- 
side of it. 

Traction on the forceps is combined with suprapubic 
pressure and the combination is most efficient. If forceps 



246 CASE HISTORIES IN OBSTETRICS. 

had not been applied to the after-coming head in Case 36, I 
doubt if the result would have been so good. A baby will 
stand considerable pulling and mauling but the best results 
unquestionably are obtained with the minimum traction. 
For this reason if with two or at most three strong tractions 
on the baby's body and neck combined with intelligent 
suprapubic pressure no advance is obtained then put forceps 
on the after-coming head at once. My chief reason for ad- 
vising this procedure is because it takes the terrific strain 
off the neck muscles and ligaments which all physicians know 
must necessarily come in a hard extraction. Many times 
I have seen much force used in the traction and the baby 
finally delivered only to die in a few moments when if forceps 
had been applied the results might have been otherwise. 
By the use of the forceps less traction is needed on the neck. 
Forceps to the after- coming head is oftentimes one of the 
hardest obstetric operations there is to perform. And be- 
cause of the difficulty one may encounter with an after-com- 
ing head, a hard extraction by the breech becomes a very 
serious obstetric procedure. I well remember helping a 
skilled physician with a version and extraction that he had 
to perform. He asked me to come with an etherizer to help 
him. When the preparations were completed and the patient 
etherized he did a beautiful version and extraction as far 
as the arms. These he found extended. He attempted to 
deliver the posterior one but could not bring the arm down. 
His hand was tired and I at once attempted to get the arm 
and succeeded and then turned the baby so that the anterior 
arm became the posterior. He then delivered this arm after 
much difficulty. Traction on the neck with most excellent 
suprapubic pressure gained nothing and he then put forceps 
on the after-coming head while I held the body as above 
described out of his way. By hard traction on the forceps 
and suprapubic pressure the head was extracted and he 
gave the baby to me to resuscitate while he stayed scrubbed 
up to look after the third stage. The baby soon cried and 
was apparently none the worse for its hard delivery. I 
mention this case to show the importance of having help at 
hand in a difficult delivery. 



VERSION. 247 

One may say that such help cannot always be had even if 
it is sought. It must be planned for ahead of time. Physicians 
must be willing to call upon each other. The difficulty is 
not that help cannot be obtained but arises from the fact 
that the majority of physicians do not think and plan ahead. 
They dislike to call for assistance when there finally may be 
no real need. Except in grave emergencies a version and 
extraction ought not to be attempted unless a second phy- 
sician is present. 



SECTION IX. 

ACCIDENTAL HEMORRHAGE OF PREGNANCY. 

Case 37. Premature Separation of a Normally 
Implanted Placenta. April 9. Patient is seen this morn- 
ing for the first time at about seven-thirty, in consultation. 
The following story is obtained: The patient is nearly at 
term in her first pregnancy as her last menstruation was 
on July 3rd. She has had an absolutely normal pregnancy. 
Her blood pressure has not been over 120 mm. and there has 
at no time been any albumin in the urine. At half-past 
five this morning she got up out of bed and went to the 
bathroom to have a dejection, and as she came back to bed 
she was seized with a sudden sharp pain in the left lower ab- 
domen. She then noticed that there was some moisture 
at the vagina and on investigating she found that blood was 
coming away. She sent at once for her physician and he 
saw her about half- past six. She was then having slight 
abdominal discomfort and there was a slight trickling of 
bright red blood from the vagina. He did not examine her 
but sent her at once to the hospital and sent for me. 
When I saw her she had good color and was complaining 
only of slight abdominal pains. She had no fresh bleeding 
from the vagina, only a slight amount of dark colored blood. 
Her pulse was 86, of good quality, and temperature was 
98.6°. Palpation of the uterus showed a full term uterus, 
though apparently a small baby. The head was above the 
brim. Position not determined. On palpating the uterus 
the patient complained that it hurt her, especially on the left 
side. Contour of the uterus was normal. The uterus was 
harder than normal and at no time did it completely relax. 
No fetal heart heard. Vaginal examination showed a tight 
vagina; cervix was not taken up and the os not dilated. 
There was no sensation of any bogginess in the lower uterine 
segment. 

248 



ACCIDENTAL HEMORRHAGE OF PREGNANCY. 249 

Diagnosis : Premature separation of a normally implanted 
placenta. 

Treatment: I advised that a Csesarean section be done 
at once as the operation of election. My reasons for this 
advice were that the diagnosis I felt was correct and there- 
fore the treatment indicated was to empty the uterus as 
quickly as possible. In the presence of an undilated birth 
canal, Csesarean section was the safest procedure. The 
advice was accepted by the husband and wife with the 
understanding that the baby was probably dead at this 
time. 

Preparations were immediately completed for a Csesa- 
rean section. The abdomen was dry shaved and when every- 
thing was completed she was etherized and the abdomen 
prepared with iodine. An incision to the left of the umbili- 
cus and at its level was made. Coincident with this in- 
cision 10 minims of ergatol and i cc. of pituitrin were given. 
The abdomen was opened without incident. No walling- 
off gauze was placed. Uterus incised and in making the 
incision the membranes presented. As the incision in the 
uterus was completed it was seen that there was blood coming 
from between the uterus and the membranes. Beneath the 
membranes was seen meconium stained liquor. Membranes 
immediately incised and meconium stained fluid escaped. 
A dead baby was immediately extracted. The placenta was 
found, almost entirely separated on the left side. Between 
the membranes and the uterine wall was a thin layer of 
blood over nearly three-quarters of the entire uterus. By 
the time the baby, the placenta, and the blood clots were 
removed the uterus was contracting, and although there 
was bleeding there was no question of doing a hysterectomy. 
Uterus was now sewed up with interrupted deep sutures of 
chromic catgut No. 2, and a superficial layer with No. 2 
catgut, then the entire incision oversewed with chromic 
catgut. The patient's pulse as the uterus was being sewed 
was 160. Some of this was due to the fact that she was 
under very slight ansesthesia. Uterus continued to act well 
and before the abdomen was closed several large clots were 
expelled by vagina. The abdomen was closed in layers in 



250 CASE HISTORIES IN OBSTETRICS. 

the usual manner. She went off the table with a pulse of 
120 in good condition. 

Catheter specimen of the urine just before operation 
showed it to be normal in color, reaction acid, specific grav- 
ity 1.004, slightest possible trace of albumin by nitric acid 
and by heat. Sediment showed a few renal cells, an occa- 
sional leucocyte, but no casts were seen in the one specimen. 

April 15. Telephone message to-day from the doctor in 
charge saying that with the exception of considerable nausea 
and vomiting after the operation the patient made an excel- 
lent recovery and at no time has the temperature been over 
99°, the pulse running between 70 and 90. In every wayjs 
her condition satisfactory. Her breasts filled up on the third 
to fourth day but rapidly subsided by being left alone. 

Case 37A. Premature Separation of a Normally 
Implanted Placenta. July 19. Telephone message from 
my house officer saying that a physician had just sent in a 
case to the hospital with a diagnosis of' placenta praevia, 
that the vagina is packed and that she is bleeding slightly. 
Pulse 80, temperature 98°. The house officer says she is 
in slight labor and in good condition, though somewhat 
anemic. I saw her at once and got from her the following 
story. She thinks she is about eight months advanced in 
her second pregnancy. Her first pregnancy terminated in a 
normal delivery and the child is living and well. She waked 
up this morning at six o'clock and found she was bleeding 
slightly from the vagina. Slight labor began at half-past 
six and she sent for a physician at once. When he came he 
packed the vagina and sent her to the hospital. She arrived 
at the hospital at half -past nine and I saw her about ten. 
She then had a pulse of 80. Her pallor was marked. Pal- 
pation showed the abdomen was tense. Uterus was the size 
of a full term pregnancy. Palpation of the fetus was not 
satisfactory though I thought the vertex presented. Pal- 
pation caused much pain. The uterus was tight, although 
slight contractions of the uterus were evident. No fetal 
heart was heard. Preparations for vaginal examination were 
immediately made and two small strips of gauze were re- 
moved from the vagina. No bleeding accompanied the 



ACCIDENTAL HEMORRHAGE OF PREGNANCY. 25 1 

removal of these strips. Os was then found to be dilated 
four fingers and very thin; no placenta was felt. Mem- 
branes were not ruptured and a vertex was presenting. 

Diagnosis: Separated placenta. 

I advised that she be delivered at once and she accepted 
this advice. The fact that she was four fingers dilated 
and cervix very soft, manual dilatation to full dilatation and 
delivery seemed the operation of election. Preparations were 
completed for the delivery. She was etherized and dila- 
tation carried to full dilatation with great ease. Her pulse 
rose to 150 and her pallor was very marked. Pituitrin was 
then given subcutaneously, followed at once by ergot. The 
baby was lying in the left anterior position and an internal 
podalic version was readily done. The baby was extracted 
and with it came many large clots, some fresh blood and 
the placenta and membranes. The baby was dead. Ether 
was stopped. The uterus acted well and although there was 
no bleeding, it was packed with three yard packing strip. 
One ampule of ergot was given. There was no fresh perineal 
tear. She was put back to bed in marked shock and given 
a shock enema. Pulse was 150 and of fair quality. Uterus 
was held and as she was coming out of ether she was given 
one-sixth of morphia as she began to be restless. There was 
no bleeding. Pulse, though rapid, 150, steadily improved in 
quality and late in the afternoon had dropped to 100. 

July 20. Temperature this morning 98.6° and pulse 84. 
Uterine packing was removed this morning and she was 
given a sterile water intrauterine douche followed by one 
pint of 70 per cent alcohol. To-night temperature went to 
99.4° and pulse 90. She is in excellent condition. She is 
taking soft solids and drinking plenty of water. 

July 21. Temperature 98.6° and pulse 80. Uterus is not 
tender and is well contracted. Three finger breadths above 
the symphysis. 

July 22. Temperature this morning normal. Pulse 74. 
Breasts are slightly full. She is having ergot one dram three 
times a day. Temperature to-night 100.6° and pulse 84. 
Except for slight discomfort in the breasts she is in excellent 
condition. 



252 CASE HISTORIES IN OBSTETRICS. 

July 25. Uterus involuting well. To-day is the tenth 
day and the patient sat up in bed. Her color is improving 
very rapidly. She is doing well and has absolutely no un- 
toward symptoms. 

July 29. Out of bed to-day. Lochia has practically 
ceased. 

August 2. She is examined to-day for discharge. Perin- 
eum fair. Cervix shows stellate tear. Involution of the 
uterus is good. Position is good and the vaults are nega- 
tive. She is not flowing any. Pulse to-day is 70, and the 
temperature has varied from normal to 99° in the past three 
days. 

Summary of Accidental Hemorrhage of Pregnancy. 

The above cases are on the whole fair examples of the so- 
called accidental hemorrhage which takes place in pregnancy. 
The term accidental is applied to this type of bleeding in 
distinction from the bleeding from placenta prsevia which 
is unavoidable. By accidental we do not mean that trauma 
is necessarily the cause of this condition. Trauma either 
direct or indirect may be the cause. Disease of the pla- 
centa or of the uterine mucosa has been suggested as re- 
sponsible for the condition. Many times no obvious cause 
can be found to explain the accident. Recently it has been 
suggested that a toxin may be responsible for this condi- 
tion but as yet this theory has not been verified by other 
observers. Hydramnios with the sudden emptying of the 
liquor from the uterus may be the exciting cause. 

The signs and symptoms of this condition vary accord- 
ing to the type of hemorrhage which is present, that is, 
whether the bleeding is external or internal, concealed, or 
these two combined. The one certain symptom which has 
been present in all cases I have seen is a change from normal 
in the contractions and feel of the uterus. This was present 
in these two cases. In the one case (Case 37) the uterus 
was described as harder than normal and at no time did it 
relax completely. In the other case (Case 37A) the uterus 
was tight. 

Pain is another symptom which is always present. This 



ACCIDENTAL HEMORRHAGE OF PREGNANCY. 253 

may vary from simple discomfort to severe cramplike pain 
localized at the point of separation of the placenta from 
the uterus, in other words at the seat of the hemorrhage 
(Case 37). Accompanying the pain is tenderness of the 
uterus to palpation. As the bleeding continues, the uterus 
becomes hard, boardlike and exquisitely tender on pal- 
pation. The more completely the bleeding is concealed, 
the more boardlike is the uterus on palpation. Whether 
the bleeding is external or concealed depends upon the po- 
sition of the placenta in the uterus, upon the amount of 
hemorrhage, upon the tone of the uterine musculature and 
probably upon the denseness of adhesions between the mem- 
branes and the uterine mucosa. Some writers have reported 
the uterus soft and boggy. I have never yet seen this type 
of uterus. 

This condition of accidental hemorrhage of pregnancy 
may occur without labor having begun. The patient may 
be found in profound collapse with no external bleeding or 
at most a very slight show of blood or blood-stained serum. 
Irregularity of the uterine contour may be found with great 
tenderness where this irregularity is. The fetal heart may 
or may not be heard, depending entirely upon how much 
of the placenta has separated. At the beginning of a sep- 
aration the maternal pulse usually does not show much 
alteration in rate. Not infrequently even after the separa- 
tion is complete, when the bleeding is chiefly concealed, the 
rate does not materially increase and if one goes entirely 
by the rate, the patient's true condition is not determined. 
This point is well shown in Case 37A where the pulse rate 
was only 80, yet the moment we began delivery it jumped 
to 150. In cases of this type the pallor is oftentimes the 
striking sign. 

In this complication of pregnancy as soon as the diagnosis 
is made the uterus must be emptied as quickly as is possible. 
The condition of the birth canal will determine the method 
chosen to effect delivery. The above two cases show the 
reasons for the choice of method. In the first, the birth 
canal was rigid, in the second, soft and dilatable; for the 
first I therefore elected a Csesarean and for the second man- 



254 CASE HISTORIES IN OBSTETRICS. 

ual dilatation and version. In some cases where the birth 
canal is dilated, craniotomy may be the operation of election. 
Many obstetricians will elect to do a Caesarean section for 
this complication under all circumstances. This I do not 
believe to be a proper position to hold. It is true that should 
the uterus fail to contract and the bleeding be uncontrol- 
lable, hysterectomy may be done at once. I am confident 
that time is a very important element in the successful man- 
agement of these cases and if good results are to be obtained 
obstetricians must not delay at all or at most very little in 
the emptying of the uterus, but I am confident a Caesarean 
section is not always indicated. 

If the patient is in labor and the uterus acting well, in 
a few cases a Voorhees bag may be inserted to hasten the 
dilatation of the cervix. If a bag is used, as soon as it comes 
through the cervix the uterus should be at once emptied. 
Proper precautions must be at hand to meet a possible post- 
partum hemorrhage, and if much blood has already been 
lost the uterus should be packed without delay. In severe 
cases of this complication the patient may have to be trans- 
fused either during delivery or immediately after it. If 
means for a direct transfusion or for an intravenous salt 
solution are not at hand, then salt solution must be given 
by rectum either slowly by the drop method, or four to six 
ounces, every four hours. I have had no personal experience 
with the use of pituitrin or of ergot in small doses in order 
to increase the contractions of the uterus. In one of the 
above cases (Case 37A) I ordered an ampule of ergot and 
one of pituitrin as I was about to deliver, but I was confident 
that there would be no delay in the delivery of the baby 
or the placenta and that contraction of the uterus was of 
paramount importance. 

There can be no definite treatment for this condition; 
there are too many variable factors present. The one point 
to keep constantly in mind is that the uterus must be emptied 
as quickly as is possible. In many of these cases the baby 
is dead and need not be considered. The method of deliv- 
ery which gives the least amount of shock to the mother, 
other points being equal, is to be chosen. 



SECTION X. 
UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 

Case 38. Partial Placenta Previa. Manual Dila- 
tation. Version. Extraction. The patient is seen in 
consultation May i8th. She is within two weeks of term 
in her first pregnancy. There is nothing to note of interest 
in her pregnancy until four weeks ago when without any 
known cause she was flooded by a sudden, sharp, short 
hemorrhage. She did not faint. She had no pains. She 
went at once to bed and telephoned for her physician. He 
saw her within half an hour and found her with a pulse of 80, 
bleeding but slightly. She had good color. There were no 
contractions of the uterus. He did not examine her at this 
time. Bleeding stopped entirely within three hours. She 
was kept in bed for three or four days and as there was no 
bleeding she was allowed to get up. The physician examined 
her the day she got up and at that time made a diagnosis of 
placenta praevia. 

From then until to-night she had no more bleeding. She 
was in bed and was waked up by the flowing. She at once 
telephoned for her physician. When he saw her she was 
bleeding freely and had passed one clot the size of a man's 
fist. 

I saw her within an hour of the first bleeding. She was 
not flowing. Pulse 90, regular and of good volume. Color 
good. Palpation of abdomen shows a full termed pregnancy. 
Position of fetus probably O. L. A. Presentation vertex 
with the head floating. While palpating the abdomen it 
was seen that the uterus was contracting. She said she had 
been having pains in her back for the last half hour. Con- 
tractions were now coming every five minutes and were in- 
creasing in severity. Fetal motion seen. 

Vaginal Examination: — Small introitus. Blood clot 
present in the vagina. Cervix is flush with the vaginal 

25s 



256 CASE HISTORIES IN OBSTETRICS. 

vault and in pressing the examining finger in either lateral 
cul-de-sac, it comes upon a soft, doughy mass. Examina- 
tion was not persisted in and no attempt was made to de- 
termine accurately the limitations of this soft mass or the 
amount of dilatation of the os uteri. 

Diagnosis: Placenta praevia. 

Treatment: I advised immediate delivery of the patient 
at the local hospital. The advice was accepted by the 
husband and wife and she was at once taken to the hospital. 

The vulva was then shaved and she was carefully prepared. 
Slight bleeding again began. By the time she was prepared 
the instruments and other preparations for delivery were 
ready. 

She was etherized and placed in moderate lithotomy posi- 
tion. Catheterized. The vulva and vagina then carefully 
washed with 70% alcohol. The vagina and perineum care- 
fully and slowly dilated until the closed fist could be flexed 
out readily. Dilatation of cervix now begun. The cervix 
was fully taken up, the os uteri dilated two fingers and soft. 
Forefinger and thumb of the left hand readily pushed inside 
the OS. Without difiiiculty dilatation was slowly and care- 
fully carried up to full dilatation. As the dilatation was 
completed some of the placenta was necessarily loosened and 
it was then seen that most of the placenta was on the patient's 
left. The closed fist was brought down through the cervix 
three times. It was intact and offered no resistance to the 
closed fist. 

With resistance on the fundus I then pushed the edge of 
the placenta, which was on her right towards her left pelvis 
with my left hand and then went up between the membranes 
and the uterine wall, peeling the membranes off, until I 
thought I was high enough to reach a foot. I then ruptured 
the membranes. My forearm acted as a cork, very little 
liquor came away. I felt for a foot and it was obtained with 
but little difhculty. I now told the etherizer which way I 
was going to turn, namely, I was drawing the leg down on the 
patient's right, and the head was going up on the left. He 
gave me material help in turning. The foot seized proved to 
belong to the anterior leg. It was brought down very readily. 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 257 

A Sterile towel was placed about it and with downward 
traction the posterior buttock was brought to the peri- 
neum. Finger was then put into the groin and with down- 
ward traction and lateral flexion of the body of the baby 
the buttocks were delivered. The bis-acromial diameter of the 
baby was now kept in the right oblique diameter of the 
mother^s pelvis and traction brought the angles of the scapulae 
into view. The perineal arm now sought with the operator's 
left hand. It was extended and after one or two attempts 
it was reached, brought down and swept out over the baby's 
face. The right arm was also found extended. The shoulders 
were readily turned into the left oblique diameter and the 
arm sought for and delivered. Excellent suprapubic pres- 
sure was now given and with but little difficulty the head was 
extracted. 

The child gasped at once and in a few moments cried. 
The patient began to bleed at once profusely and the cord 
was immediately clamped and cut. The hands washed off 
quickly in 70% alcohol and then the placenta was removed 
manually. There was a tremendous gush of blood. I at 
once thrust my left hand into the vagina, my right hand above 
on the fundus as counter-pressure, and seized the cervical 
ring with my fingers in the culs-de-sac. This for the mo- 
ment stemmed the bleeding and with massage on the outside, 
combined with ice, the uterus soon contracted. Ergot was 
given in the meantime intramuscularly. 

Her pulse was now 120, but of good quality and she looked 
in fair condition. She was at once given a hot salt solution, 
intra-uterine douche and the uterus began to act steadily 
better. The bleeding became less and less. I was prepared 
to pack the uterus, but because of the steady improvement 
in the action of the uterus and because the bleeding became 
less and less I decided not to pack it. 

There was a median perineal tear of the second degree, and 
I rapidly placed and tied three silkworm-gut sutures. The 
patient was cleaned up, a vulval pad was put in place and 
she was then put back to bed in very fair condition with a 
pulse of 120. 

The uterus was carefully held for an hour and it remained 



258 CASE HISTORIES IN OBSTETRICS. 

well contracted with only the normal amount of bleeding 
present. 

She made an excellent ether recovery, pulse steadily 
dropped, and when I left two and a half hours after the 
delivery, she had a pulse of 72, of excellent quality. 

The baby weighed seven and a half pounds, and was in 
excellent condition. 

June I. Note from the attending physician stating that 
the patient ran a slightly irregular temperature for the first 
few days. At no time, however, did the temperature rise 
over 100.4°, and the highest the pulse reached was 102. 
She is now up and about the hospital and will go home in 
a few days. The baby dropped to seven pounds and then 
began to gain. The mother is nursing. Lochia has ceased 
and there is no vaginal discharge. 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 259 

Case 39. Separation of a Low Attached Placenta. 
Low Forceps. Puerperal Salpingitis. The patient went 
through her pregnancy without difficulty. Her two previous 
pregnancies terminated in normal deliveries of seven and 
a half and eight-pound babies. The last child was born 
eighteen months ago. She expects her labor between the 
fifteenth and the twentieth of July. She is in excellent 
condition. All urinary analyses have been normal. Palpa- 
tion of the abdomen July ist showed a large abdomen, con- 
siderable amount of liquor present. Baby is freely movable. 
Small parts felt distinctly on the left with back on the right. 
Head is free above the inlet. 

July 17. Last night she was very uncomfortable from 
irregular pains both in time and in severity. At no time 
did they come oftener than once in thirty minutes, but 
when they came they waked her up. 

Palpation : — Head is firmly fixed at the brim. Palpa- 
tion is unsatisfactory as the uterus is very irritable and when 
touched contracts but without pain. Baby is very lively and 
causes much discomfort. Fetal heart is 140 in the right 
lower quadrant. 

July 18. To-night at midnight patient was awakened by 
the breaking of the waters. She found the bed well soaked 
with blood-stained waters, and telephones that there was a 
slight discharge of bright red blood. I saw her at once. 
Abdomen much smaller. Fetal heart 130. Head well en- 
gaged in the brim. She says that the pains are coming once 
in fifteen minutes, are short and not severe. 

Vaginal Examination : — Cervix thin ; os dilated three 
fingers. Careful examination, but no placenta is reached. 
Head is in the mid-pelvis. Sagittal suture is in the right 
oblique diameter and the posterior fontanelle is readily made 
out near the right sacro-iliac joint. 

Two A.M. Pains still coming slowly, but of better strength 
and longer in duration. Fetal heart regular at 130; mater- 
nal pulse 80. There now is bright red flowing, distinctly 
more than the normal case shows. There is no alteration of 
the fetal heart and no rise in the maternal pulse. The uterus 
is relaxing well between pains. 



260 CASE HISTORIES IN OBSTETRICS. 

Four A.M. From two until now there was no abnormal 
amount of show. The fetal heart has been listened to every 
half hour and there was no alteration in the rate. The pains 
were now coming every five minutes lasting one minute. 

At four-thirty a.m. more bleeding occurred. Vaginal ex- 
amination : — Os uteri two- thirds dilated and on the posterior 
wall of the uterus could be felt a soft pudgy mass, the free 
edge of which could be felt anterior to the posterior lip of the 
cervix. The head was just above the mass impinging on the 
upper part of this tongue of the placenta. There was blood 
on the examining finger. 

As the pains were coming now every five minutes and there 
was no excessive bleeding and the maternal pulse and fetal 
heart showed no change, I decided to let her go on in labor 
hoping the on-coming head would successfully press down on 
the detached placenta and stop all further bleeding. The 
fetal heart now listened to every fifteen minutes and until 
half-past five it stayed regular at 130. I now found it to be 
180, but regular, and shortly after it dropped to 100, but 
regular. Maternal pulse had gone from 80 to no. I ad- 
vised operative delivery in the interest of the baby at once. 
Preparations for delivery were speedily completed. Just 
before she was etherized the fetal heart listened to and found 
to be regular, 140 to the minute. Etherized, lithotomy 
position, with leg holder. Prepared in usual manner. 
Large clot of blood in the vagina, which was removed. 
Vagina wiped out with 70% alcohol. Examination showed 
that the os had retracted over the head. Head on the per- 
ineal floor, the sagittal suture in the antero-posterior diam- 
eter; posterior fontanelle at the arch of the symphysis. 
Perineum quickly dilated and the forceps applied to the 
sides of the pelvis and readily locked. On the first traction 
the head descended, followed by extension, and delivery very 
quickly accomplished. Baby cried at once. The cord was 
not pulsating and was clamped and cut. 

The uterus contracted hard, but at once there came a 
steady ooze of blood. Patient's pulse no. On the second 
contraction I expelled the placenta because of the steady 
flow. The placenta was intact and with it came all the 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 26 1 

membranes and several small clots. Ergot was given in- 
tramuscularly. The uterus acted well and there was no 
further excessive bleeding. Examination of the perineum 
showed no fresh tear. She was cleaned up and a sterile 
vulval pad put on. The bleeding was soon within normal 
limits. The patient's pulse steadily dropped and an hour 
after delivery was 90 and of good quality. The uterus was 
held carefully because it had a slight tendency to relax. At 
the end of two hours it remained well contracted and there 
was no more bleeding than normal. 

The baby was in excellent condition and weighed eight 
pounds. 

The convalescence until the afternoon of the tenth day 
was absolutely uneventful. The baby nursed well and was 
satisfied. The highest the temperature reached was on the 
night of the fourth day when it was 99.6°; pulse 80. The 
breasts were full and tense. Bowels moved regularly every 
day. Lochia was sufficient; normal in odor and color. 

The afternoon of the tenth day she was found to have a 
temperature of 102°; pulse 104; respiration 24. She com- 
plained of pain low down on the left side of the abdomen. 
The pain is a constant dull ache. She is able to lie on either 
side but is more comfortable on her back. She says she has 
had this pain off and on ever since she was married but has 
never had to go to bed with it, and it has never been severe 
enough to have a physician. 

Physical Examination: — Throat and chest negative. 
Breasts full but not tender. Abdomen slightly distended 
and tympanitic throughout. There is no tenderness in 
either kidney region or in the upper abdomen. On deep pal- 
pation the fundus of the uterus can just be felt. It is firm 
and not tender. There is no tenderness in the right lower 
quadrant. Palpation of the left lower quadrant shows 
slight spasm on deep pressure and the patient complains 
of pain. No mass is felt. Examination of both legs is 
normal. 

On the pad the patient had on there was a thick, yellowish 
discharge with foul odor. 

Diagnosis: Puerperal salpingitis. 



262 CASE HISTORIES IN OBSTETRICS. 

Treatment : Ice-bag constantly to the left lower quadrant. 
Enema at once and then half an ounce of castor oil, to be 
followed in two hours by another enema. 

July 29. Another physician saw her for me to-day and 
the following notes are his: '' Marked tenderness but not true 
spasm in the left lower abdomen. Abdomen otherwise nega- 
tive. Vaginal examination : — Os tight ; uterus well involuted. 
There is a tender mass the size of a hen's egg in the left cul- 
de-sac. Lochia profuse yellowish and foul smelling. Tem- 
perature 102°; pulse 120." 

Treatment : He advised and gave an intra-uterine douche 
of corrosive sublimate 1-10,000. He had to dilate the cervix 
with a Goodell dilator in order to insert the douche nozzle 
into the uterus. This was accompanied by some slight 
bleeding. The first of the douche brought away considerable 
milky colored fluid. 

Half an hour after the douche was given the patient had a 
severe chill, lasting for fifteen minutes. Temperature taken 
after the chill was over and found to be 104.2°; pulse 130. 
The ice was continued to her left lower abdomen. Nine p.m. 
temperature 101°; pulse 104. Less abdominal tenderness 
and no spasm. 

July 30. Slept well last night. Profuse yellowish vaginal 
discharge of foul odor. Very slight abdominal tenderness. 
Temperature this morning 100°; pulse 92. She is having 
a light diet of soft solids. Bowels have moved twice since 
last visit. Temperature this evening 99°; pulse 92. No 
tenderness in abdomen. Vaginal discharge much less in 
amount, still foul. Ice continued as before. 

July 31. I saw her to-day. Temperature 98.6°; pulse 80. 
Abdomen negative. Vaginal discharge has practically 
stopped. Ice-bag removed. Bowels kept open with cascara. 

August 3. She got up to-day for an hour with no unto- 
ward result. Temperature normal ; pulse 80. From now on 
she steadily gained strength and was soon about in her usual 
condition. She refused to have a pelvic examination the 
last time I visited her. 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 263 

Summary of Puerperal Salpingitis. 

This case is instructive from two points of view, first, the 
management of a partial placenta prsevia and second, the 
diagnosis and management of a puerperal salpingitis. Dis- 
cussion of the first will be taken up in the summary of pla- 
centa praevia. 

The history and physical findings in this case are typical. 
The closer an attack of acute salpingitis comes to the delivery, 
the more difficult it is to differentiate from uterine sepsis. 
Careful weighing of the signs and symptoms usually will clear 
the diagnosis. In an attack of puerperal salpingitis the pulse 
and temperature do not rise generally for at least three days, 
more often not until the first week. The patient then is 
found complaining of pain on the affected side and the 
temperature shows a marked rise to 102° or 104°, but the 
pulse usually does not rise correspondingly. The patient 
does not appear at first sick. Complete physical examination 
rules out one organ after another until the pelvis is reached. 
Here the uterus usually can be palpated but it is not tender 
or soft as one finds it in a septic condition. If it is tender at 
all, careful palpation will show the tenderness localized at 
the point where the affected tube enters the uterus. Spasm 
of varying degrees is found over the affected tube. It may 
and often is so slight that tenderness alone is noted. The 
lochia varies much depending entirely upon whether the tube 
is draining through the uterus or not. If it is not the lochia 
corresponds to the usual progress of the puerperium. If 
the tube is draining the lochia is foul smelling, looking like 
pus. Any combination is therefore possible from normal 
lochia to a profuse purulent discharge. Vaginal examination 
is not remarkable. If the patient has had a long standing 
salpingitis then a mass may be found; but when the attack 
comes early in the puerperium and involution has proceeded 
but little, usually nothing definite is found. In this case on 
the eleventh day a small mass was palpated. 

When the attack is left sided the diagnosis is relatively 
easy, but if it is right sided the differentiation between it 
and appendicitis is not easy. In appendicitis the tempera- 



264 CASE HISTORIES IN OBSTETRICS. 

ture does not usually rise so quickly and if it does the pulse 
more nearly corresponds. In appendicitis, vomiting or 
nausea is usually present, but they are not in puerperal sal- 
pingitis. Spasm in an acute appendix is more marked than 
in salpingitis. 

The treatment of a puerperal salpingitis that has been most 
satisfactory in my hands is to apply an ice-bag to the affected 
side, give mild catharsis, a light diet and if the pain is severe, 
small doses of codeia enough to relieve the pain but not 
enough to hide any possible symptoms. If the attack is 
right sided and appendicitis cannot be ruled out, then the 
bowels should be moved by enema, the patient starved and 
no opiate given until the diagnosis is cleared. 

The treatment of this case I regard as absolutely bad, for 
with a diagnosis of puerperal salpingitis, an intra-uterine 
douche never should be given. The evil result of douching 
in this condition is well shown in this case by the chill which 
followed. As soon as the pressure of the pus in the tube is 
sufficient it breaks down into the uterus and discharges. In 
this case the tube was already draining and there was not 
the slightest indication to give an intra-uterine douche. I 
have never seen a tube rupture into the abdominal cavity. 
There is no reason why it should not occur, and if it should, 
the question of opening the abdomen might arise, but the 
general statement may be made that when a pelvic perito- 
nitis occurs in the course of the puerperium it is usually much 
wiser to let nature manage the condition and keep the surgeon 
away. Nature's healing powers never are better shown than 
in puerperal infections, where there are large exudates in 
the pelvis. These are absorbed sometimes slowly, not infre- 
quently with remarkable rapidity and leave no apparent 
damage to the pelvic organs. 

If the temperature and pulse drop to normal after a diag- 
nosis of puerperal salpingitis has been made and continue 
to remain normal, one may feel reasonably certain that the 
pelvic condition is clearing up satisfactorily. But if the 
temperature and pulse are slightly elevated one must be on 
guard for the formation of a pelvic abscess. Careful pelvic 
examination alone will confirm the diagnosis. One examina- 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 265 

tion alone will not always settle the diagnosis but repeated 
ones of two days' intervals will undoubtedly settle the pelvic 
condition. If a pelvic abscess develops in a puerperal case 
and an operation is indicated, a vaginal section or puncture 
is always the operation of election. 



266 CASE HISTORIES IN OBSTETRICS. 

Case 40. Complete Placenta Previa. Voorhees Bag. 
Version. Patient is sent into the hospital on November 
26th with a diagnosis of complete placenta praevia. She 
entered the hospital at half- past ten a.m. with a pulse of 120, 
temperature 99°. She says her last menstruation was Feb- 
ruary 22nd and she expects to be confined at any time now. 
She has had a normal pregnancy up to one week ago when 
she began to flow slightly. She would flow a few drops at 
intervals during the day, a sufficient amount, however, to 
have to wear a pad. She has been up and about her home 
and last night about nine p.m. without warning she had a 
sudden profuse hemorrhage. She immediately went to bed 
and sent for a physician. She has had no pains. When she 
entered the hospital she was not flowing. Palpation shows 
a vertex presentation. Occiput left anterior. Large baby. 
Uterus soft. Patient not in labor. 

Vaginal Examination : — A vaginal pack presents. Re- 
moved, soaked with bright red blood. Cervix is not fully 
taken up. Os is rigid and dilated one finger. About the 
OS can be felt a definite boggy mass. Presenting part is not 
in the pelvis. Promontory cannot be reached. Outlet is 
ample. 

I decided because of the rigid condition of the cervix and 
the size of the baby that it was a question of putting a bag 
in through the placenta in order to soften and dilate the cer- 
vix or of doing a Caesarean section. After due deliberation 
I decided to put a bag in under ether. The chief reason for 
deciding against a Caesarean section was because of the vaginal 
pack which the patient said had been in the vagina since last 
night. After the usual preparations were completed a four- 
inch bag was put in through the cervix and an attempt was 
made to thrust it through the placenta. There was a sharp 
hemorrhage when the bag was pushed through the cervix. 
This ceased as soon as the bag was dilated. Bag was put in 
at twelve o'clock noon. Pains began almost at once and 
with each pain the bag was gently pulled. Fetal heart was 
carefully watched as was also the maternal pulse. There was 
no bleeding and no increase in the pulse rate, maternal or 
fetal. At half-past four bleeding became marked and the 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 267 

patient's pulse rose to 130. I decided then to deliver her 
at once. 

The bag was removed and the cervix found to be two- 
thirds dilated and very soft. Examination then showed that 
the bag did not go in through the placenta but only within 
the internal os beneath the placenta. Dilatation of the os 
uteri was completed readily and quickly. The hand was 
brought through the cervix three times and there was no 
resistance felt. The placenta was entirely over the dilated 
OS. With resistance on the fundus from the assistant I then 
went up through the placenta with my left hand and seized 
the anterior leg. It was brought down quickly. The hem- 
orrhage on going through the placenta was considerable. As 
soon as the leg was brought down however it ceased. Version 
was completed as quickly as was consistent with safety to the 
maternal soft parts. The bistrochanteric diameter came down 
in the right oblique diameter. The left arm was the perineal 
arm and was readily delivered and the right, the anterior, was 
then made the perineal. Rapid extraction of this arm followed. 
The baby was put across the right forearm and grasped about 
the neck, and with excellent suprapubic pressure the head 
was delivered without any difficulty but with a severe tear 
of the perineum. Baby was a large male child and was in 
pallid asphyxia. It gasped slowly and was put in hot water 
and gradually resuscitated by an assistant. Examination of 
the perineum showed that there was a tear through the 
sphincter but not into the rectum. There was profuse 
hemorrhage and with a fresh pair of sterile gloves I went into 
the uterus and removed manually the placenta with all its 
membranes. It was then seen that the cervical ring and the 
uterus were intact. Uterus acted badly, profuse bleeding 
continued. Ergot given intramuscularly. The uterus was 
packed at once with a five-yard packing strip of gauze. 
Bleeding immediately became less. Ergot was repeated. 
The bleeding gradually ceased. Pulse rose to 140 and the 
patient's condition was only fair. Three chromic catgut 
sutures placed in the deep perineum brought the internal 
tear well together. The torn ends of the sphincter were 
then seized and with chromic catgut sutures No. 2 the ends 



268 CASE HISTORIES IN OBSTETRICS. 

were sutured. Three silkworm-gut sutures then placed in 
the perineum. One supporting silkworm-gut stitch placed 
through the sphincter. The patient was at once put back 
to bed and surrounded by heaters, but no stimulation given. 

November 27. Temperature this morning 98°, pulse has 
dropped to 102. She was placed across the bed and the 
vulva wiped off with 1-3000 corrosive sublimate. With 
rat-tooth forceps the gauze was drawn out of the vagina and 
then out of the uterus. There was no bleeding. She was 
then given an intra-uterine douche of sterile salt solution 
followed by a pint of 70% alcohol. This morning her con- 
dition is very satisfactory. The baby weighed eight pounds, 
fourteen ounces and is in excellent condition. Patient's 
temperature to-night 98.8°, pulse 120. 

November 28. Temperature 98°, pulse 100. Is voiding 
satisfactorily. Uterus is hard and not tender. 

November 29. Temperature to-night 98.8°, pulse 108. 
She is in excellent condition. Perineum looks well and is 
not tender. Milk is coming into the breasts and the baby 
is nursing. 

December i. Temperature 98.6°, pulse 100. In excellent 
condition. Bowels moved to-day for the first time without 
difficulty voluntarily. As there was a diphtheria epidemic in 
the hospital and as the patient was in excellent physical con- 
dition, it seemed advisable to send her home and she went 
to-day with a trained nurse to her own home to be looked 
after by her own physician. 

December 2^^, Patient's physician reported to-day to 
the house officer that the mother and baby had made a good 
convalescence. He had taken the stitches out of the peri- 
neum and a good result had been obtained. She had control 
of the sphincter both for gas and feces. She was up and about 
the house. 



Summary of Unavoidable Hemorrhage of Pregnancy. 

Two of the previous three cases were primigravidse. From 
this it is not to be inferred that placenta praevia is more com- 
mon in primiparous cases than multiparous cases, for such 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 269 

is not the case. The essential point to remember is that any 
pregnant woman may present a placenta praevia, one of the 
most serious complications of pregnancy which a physician 
can meet. Any woman pregnant more than three months 
who has bleeding from the vagina in my opinion must be 
considered to have a placenta praevia until examination 
proves that such is not the case. If all physicians would 
take this stand, the high mortality which now occurs from 
this condition would be materially lowered. The nearer to 
term a vaginal hemorrhage occurs the more certain becomes 
the diagnosis of placenta praevia and the greater is the 
demand for instant intelligent oversight. 

Vaginal bleeding, without cause, without warning, no 
matter whether it is slight or profuse, in the last three months 
of pregnancy, demands that the physician lay out his course 
of treatment accurately at once. If a physician is called 
to a case of bleeding towards the end of pregnancy and the 
hemorrhage has stopped when he arrives, it is my firm opin- 
ion he should not then examine that patient by vagina unless 
he is prepared to meet at once a possible severe hemorrhage. 
In Case 38, I made a vaginal examination very gently and 
took care not to put my finger inside the os uteri. The 
boggy sensation that the examining finger receives when the 
placenta presents is unmistakable even through the culs-de- 
sac. That, combined with the increased pulsations that 
are so often present and the bleeding without cause, makes 
the diagnosis of placenta praevia very simple. Until the 
physician is prepared to meet the hemorrhage he does not 
care to find out whether the implantation of the placenta is 
central or one of the marginal degrees. When he is pre- 
pared it is then justifiable to determine how much of the os 
uteri is covered by the placenta. Complete praevias usually 
bleed earlier in the pregnancy than do partial ones. This 
was shown in Cases 38 and 40. 

The first bleeding may be slight as it was in Case 40 or 
profuse as it was in Case 38. In each of these cases no treat- 
ment was instituted after the first bleeding appeared except 
that the last mentioned case was kept in bed three days. 

Theoretically there is no treatment for a placenta praevia 



270 CASE HISTORIES IN OBSTETRICS. 

but to empty the uterus. The condition is one of inevitable 
hemorrhage and should be met when the mother is in good 
condition, not when she is in profound shock. Practically, 
the cervix of the uterus is the bar that holds us up in empty- 
ing the uterus at once. Any physician can divulse the cer- 
vix and empty the uterus. The object, however, is to empty 
the uterus only as quickly as is consistent with safety to the 
maternal soft parts. 

Before going further into the treatment recall Case 38. 
The diagnosis of placenta praevia was made here four weeks 
before I saw the patient and yet she had been kept in bed but 
three days following the first hemorrhage. This should 
never be allowed to occur. If the diagnosis is made and 
delivery in some form or other is not at once to be under- 
taken, what procedure is the physician-in-charge to follow? 

The patient should be put to bed immediately in a hospital 
where she can receive, when the next hemorrhage occurs, 
proper attention. If the case be surrounded at her home by 
all necessary safeguards, a nurse and physicians at all times 
within a moment's call, she may be allowed to remain at 
home and wait for the next hemorrhage, which is sure to 
come. But how often can these conditions be fulfilled? 
Even if they can be, the danger of waiting must be fully 
explained to the family and it must be made clear that it is 
against the best advice that this treatment is being carried 
out. The desire for a living child is great but the risk that 
that desire entails is oftentimes greater than is the probability 
of obtaining one. The child may be born alive only to die 
in a few hours. The delay may sacrifice the mother for the 
sake of an heir or for the baptismal rite. 

The child has its right to live but in far the majority of 
cases, the child is premature and its chances of life are slight. 
I do not feel like subjecting the woman to any undue risk 
for the sake of a frail infant whose life is, at best, most prob- 
lematical. To wait after a diagnosis of placenta praevia has 
been made is an added risk. 

The question of waiting would be considered more strongly 
in an elderly primigravida where the probability of her becom- 
ing pregnant again was slight, than in a young girl. Again the 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 27I 

question of viability of the child would alter the final answer, 
but in any case the family must be told fully the pros and 
cons of the treatment advised. When a patient has reached 
eight months' gestation and a prsevia is found, delivery with- 
out question must be undertaken. The method to be used 
for emptying the uterus will vary according to the conditions 
found. In Case 39 the flowing could hardly be called a 
hemorrhage, but it was distinctly more than is present in a 
normal case and the placenta was not felt until the patient 
was two-thirds dilated. The patient was found in active 
labor and as the bleeding was not excessive and both the 
fetal and maternal pulse showed no alteration, there was no 
indication to do anything but watch the patient carefully. 
The head came down and stopped the bleeding. As the head 
passed the placenta, more bleeding followed because the 
pressure of the neck was insufficient to check it. Care must 
be taken in these cases that no internal concealed hemorrhage 
takes place. This can be determined by careful watching 
of the fetal heart and maternal pulse. With bleeding such 
as this case showed, one must be ready to interfere at a 
moment's notice. If the cervix does not dilate and a lateral 
praevia which is bleeding is present, a large-sized dilating 
bag may be put in through the os uteri and the membranes 
and then dilated. The pressure of the bag on the placenta 
will check the bleeding and accomplish dilatation of the cer- 
vix. The moment the bag comes through the cervix, the 
possibility of an hemorrhage between the presenting part and 
the bag must be remembered. If the presenting part be a 
breech, delivery had much better be undertaken at once, 
for the soft breech does not tend to check the bleeding as 
well as the firmer head, and further a breech labor may be 
slower and the opportunity for hemorrhage greater. 

In Case 40 I attempted to put the bag directly through the 
central praevia into the amniotic sac and hoped that the pres- 
sure it exerted on the placenta would stop the bleeding and 
at the same time soften the cervix which was unusually tight 
for a cervix in a placenta praevia. I failed to place the bag 
in the amniotic cavity but I did not know this until I came 
to operate later. There is said to be less danger of sepsis 



272 CASE HISTORIES IN OBSTETRICS. 

if the bag is placed within the amniotic cavity and the danger 
from hemorrhage is unquestionably less. With a soft multi- 
parous cervix a bag will not, many times, be called for but 
where there is a rigid cervix in a primipara, its use must be 
considered. 

In the latter condition, which fortunately is rare, a Csesa- 
rean section is not contra-indicated. I am not in favor of a 
Csesarean section in placenta prsevia as a routine treatment, 
but in certain types of cases it is without doubt the best 
treatment. Case 40 more nearly approached this type of 
case than any I have yet seen. This patient was a primi- 
gravida with a complete praevia and a rigid cervix. The baby 
was large and at full term and apparently in good condition. 
These conditions must be fulfilled in my opinion if one is to 
do a Caesarean section. Besides these conditions the patient 
must not be infected. Of this condition we were not cer- 
tain, but the probability of infection from a vaginal pack in 
place some hours was great and I therefore decided against 
a Caesarean section. 

A vaginal gauze pack properly introduced will soften up 
the cervix and if labor is beginning oftentimes hurry it, but 
such a one as was put in in Case 40 is of no service. This 
one consisted simply of a piece of gauze not more than a foot 
long by two inches wide. If a pack is to be introduced it 
should be done with sufficient amount of gauze to fill snugly 
the vagina. The end should be pushed in through the ex- 
ternal OS and the cervix firmly packed and then the culs-de- 
sac. I seldom use a vaginal pack and should elect to use it 
only in a case where the hemorrhage is so profuse that it 
must be checked. Otherwise the patient's life might be 
sacrificed before preparations for operation can be completed. 
The danger of a concealed hemorrhage when a vaginal pack 
is in position must be kept in mind and the patient's pulse 
watched every few minutes. 

If the child in a placenta praevia is a small puny thing then 
a Braxton Hicks' version and extraction is the best method 
to use in delivery. The shock of such a delivery is very 
slight but in doing it one must remember that constant 
traction must be kept on the seized foot and leg and that no 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 273 

internal concealed hemorrhage can be permitted to take 
place. This is prevented by keeping careful watch on the 
patient's pulse, the feel and size of the uterus by constant 
efficient fundal pressure, and by the steady traction that the 
operator exerts on the baby's leg. By this method the baby 
is deliberately sacrificed but this is very much better than for 
a bungling operator to extract rapidly a premature baby 
which dies in a few moments and then to have the mother 
die because of a ruptured uterus. 

In the majority of praevias I believe manual dilatation will 
be the method of delivery elected. Instrumental dilatation 
has no place in such conditions. Whether the manual 
dilatation is done according to Edgar's method or by the 
Harris method will depend upon the individual operator. 
Both methods have given me equally good results. If the 
bleeding is profuse by the Harris method at the beginning 
of dilatation, one can change to Edgar's bi-manual method 
oftentimes to advantage, for by this method sometimes the 
placenta is not disturbed as much. In the dilatation the 
operator must remember that the integrity of the cervical 
ring is the essential point in the operation. Speed in dila- 
tation is of a secondary importance. Where speed in deliv- 
ery is considered and the safety of cervical ring is not, 
rupture of the uterus is sure to follow. A tiring out of the 
OS uteri must be obtained; divulsion is not wanted. After 
complete dilatation is obtained, version is the operation of 
election. In going up into the uterus to seize a foot, if 
the placenta is in the center of the os uteri, go directly 
through the placenta and never bring out the hand which is in 
the uterus until the foot sought is found. The arm against 
the placenta stops the hemorrhage and until you are ready to 
substitute the baby's leg for your arm never bring down your 
arm. If the placenta is found on one side more than the 
other, push it to the side where its greatest bulk lies. (Case 
38.) Do not in this case go through it but enter the amniotic 
sac through some part of the membranes. 

Unless there is bleeding there is no indication to hurry 
the delivery of the placenta. If there is bleeding the placenta 
must be expressed or removed manually. If the latter, 



274 <^ASE HISTORIES IN OBSTETRICS 

scrupulous aseptic technique must be followed. A fresh 
pair of sterile gloves should be put on and before the vagina 
is entered, the introitus and vagina should be thoroughly 
wiped off with 70% alcohol. Seek the line of cleavage be- 
tween the placenta and the uterine wall. At times this line 
is very easy to develop ; again it is difficult and the operation 
of manually removing the placenta becomes a serious pro- 
cedure. The whole placenta should be freed before any 
attempt to withdraw it is made. Hemorrhage after the 
removal of the placenta may be tremendous and the means 
to meet this must be at hand (page 233). 

Properly managed cases of placenta prsevia give a mor- 
tality of from three to five per cent. Hospital statistics 
however show a much greater mortality because of the poor, 
sometimes moribund, condition of patients sent in. The 
danger from a placenta praevia comes from the hemorrhage 
which inevitably must take place. Added to this is the 
increased risk of sepsis because of the fact that the uterine 
sinuses where the placenta has been attached are so close to 
the OS uteri. Because of the hemorrhage the patient's 
ability to withstand infection may be lowered and after 
having been successfully delivered she may later die from 
sepsis. 

One hemorrhage before labor may be sufficient to kill 
the patient; fortunately this is a very unusual happening. 
Even after the patient is delivered the patient may die from 
uncontrollable bleeding plus the shock of delivery. The 
shock of even an easy delivery to a patient already weakened 
by hemorrhage may be sufficient to kill her. Not a few 
patients die from a rupture of the uterus due to too rapid 
dilatation — a dilatation which in reality is a divulsion. A 
quick delivery with a rupture of the uterus is a severe arraign- 
ment of the operator. 

The prognosis for the child is bad, for even in the hands 
of skillful operators the mortality is from thirty to fifty per 
cent. Fortunately the babies in these cases of placenta 
prsevia lived. Had the baby in Case 40 been lost I should 
have held myself to blame for waiting too long. In the 
other two cases I gave very guarded prognoses for the 



UNAVOIDABLE HEMORRHAGE OF PREGNANCY. 275 

babies' lives. The reasons for this high mortality is the 
fact that the babies usually are premature, the loss of blood 
is great and the asphyxia which occurs in the delivery is 
many times very deep. Many babies die in a few days after 
a successful delivery from an aspiration pneumonia. 

I recognize fully a child's right to live, and I firmly believe 
that if the child is at full term and in good condition when 
the physician starts to operate that it is justifiable to subject 
the woman to slightly added risk for the child's sake. I do 
not believe however that it is right to subject the woman to 
any added risk if the child is premature and in poor condi- 
tion. 



SECTION XI. 
CONTRACTED PELVIS. 

Case 41. Contracted Pelvis. Intermediate Forceps. 
Patient is seen for the first time September 23. Her last 
period was May 9th. Her next period was due June 6th 
but she had no show on that day. On the 8th of June for 
a few hours she had a very sHght staining. No period in 
July, August or September. If we reckon from her May 
period, delivery will be due about the 19th of February, but 
she is quite confident that that would be too early and that 
pregnancy could not have begun until at least ten days 
later bringing labor to the very end of February or the first 
of March. She was operated on two years ago for a hernia 
in the scar following a drained appendectomy. Except for 
these operations she has been in excellent condition all her 
life and never had a serious illness. Has now no nausea or 
vomiting. Is eating and sleeping well. She is constipated 
and every other night she is taking compound licorice powder. 
I went over with her the various points in her pregnancy and 
advised her about her general hygiene, exercise and the 
drinking of water. Patient is a small, slight woman. Meas- 
urements of the pelvis show crests 23 cm. spines 22 cm., 
external conjugate 17 cm. 

December 16. Vaginal examination: — The promontory 
can just be reached without ether. Contour of the pelvis is 
normal. Ischial spines are prominent. Symphysis is normal 
and the angle of the pubic arch is slightly contracted. Bis- 
ischial diameter is 9.5 cm. 

February 17. Palpation shows a small baby at the present 
time lying in O. L. A. position. Head is at the brim, freely 
movable, but no overriding of the occiput at the symphysis 
is present. Fetal heart is 132 to the minute in the left lower 
quadrant. Vaginal examination: — With pressure above, the 
head can be sunk slightly into the pelvis. There is no real 

277 



278 CASE HISTORIES IN OBSTETRICS. 

overriding at the symphysis. Promontory can be readily 
reached. The patient remarked that the baby is pushing 
out in front and is not getting lower. 

February 22. I saw her again because of the slight ten- 
dency of the uterus to become pendulous. I took out an 
assistant to-day intending to etherize her and determine 
absolutely the size of the pelvis. On making a vaginal 
examination I found that the head had come down so that it 
could be readily reached. Then seizing the head with the 
thumb and index finger of the right hand above the sym- 
physis and pushing downward, two fingers of the left hand 
being in the vagina it is seen that the head can be pushed 
down into the pelvis. The bones of the head are soft. The 
patient is a small-boned woman and the baby at the present 
time does not weigh over seven pounds. I determined then 
to give her the test of labor with the reservation that it may 
.be necessary to do a Caesarean section after she has had a fair 
test. 

February 28. The husband telephoned at quarter past 
four this morning saying his wife was having pains every five 
minutes and that they had begun very slightly just after 
midnight. Arrived at the house at shortly after five, and 
she soon after had one pain. From then until seven o'clock 
she had no more pains. Vaginal examination at that time 
showed that with this slight amount of labor she had pushed 
the head down distinctly further than at the examination 
a week ago but the biparietal diameter is not yet through 
the brim. The cervix is partially taken up. The external 
OS admits one finger. 

At this time the husband asked if everything was all right, 
whether she would be liable to have a hard time or not. 
I told him frankly that the probability was that if she went 
into good labor she would push the head down so that a 
simple low forceps delivery could be done; that she was 
slight and small, and that the baby I thought was small also. 
I advised against a Caesarean section and told him that if 
he wanted a consultation I would send at once for a consultant, 
but I felt very confident that with good labor the head would 
come down and a relatively easy delivery would follow. He 



CONTRACTED PELVIS. 279 

accepted my advice. Fetal heart at this time was in the left 
lower quadrant, 138 to the minute. As she was not in labor 
I left the patient. I saw her again at seven in the evening. 
From seven o'clock in the morning until now she was scarcely 
in labor for she had only once an hour a pain which when it 
came did not bother her in the slightest. Her pulse remained 
at 80. Membranes were not ruptured and she had slept for 
two hours during the afternoon. She was in excellent con- 
dition and there was absolutely no indication to do anything 
and I therefore left the patient. 

At eight o'clock she began having pains every five minutes. 
I went again to her at ten and found pains coming every five 
to six minutes and lasting from thirty seconds to one min- 
ute. Palpation of the head showed it to be firmly fixed at 
the inlet. From ten until one o'clock in the morning of 
March first, she had excellent pains. Fetal heart remained 
138 in the left lower quadrant and pains were coming every 
five minutes lasting now steadily a minute. Her pulse was 
90. Vaginal examination at one o'clock showed the os 
dilated one inch. The cervix was soft and it readily stretched 
up to nearly two inches. There was present an excellent 
bag of forewaters. Head was engaging but the biparietal 
diameter was not through the brim. Pains steadily increased 
in severity with interv^als of three minutes and lasted one 
and half minutes. Uterus relaxed well between pains with 
no tenderness on palpation. At 5 a.m. palpation of the 
head from above gave the impression that the biparietal 
was through the brim. Uterus was then found to be tender 
in the left lower segment and there was also a full bladder. 
Patient voided ten ounces of urine and the tenderness very 
soon disappeared. 

At 6 A.M. vaginal examination showed the os uteri half 
dilated and very much thinner than at the previous examin- 
ation. With very slight stretching I dilated the os to two- 
thirds. At 6:30 obstetrical ether was begun. At 6:55 the 
membranes ruptured. Fetal heart immediately listened to 
and was found to be 138 to the minute. Palpation of the 
head from above showed it to be well down into the pelvis. 
At 7:15 she began to bear down with each pain. Obstetrical 



280 CASE HISTORIES IN OBSTETRICS. 

ether gave her great relief and she worked splendidly with 
each pain until half past nine. Pulse now was no. Her 
pains were of less force and she now did not work well. I 
therefore determined to deliver her. 

She was etherized and perineum was carefully dilated. 
Patient was catheterized but no urine obtained. Head was 
found held up at the ischial spines, occiput fully rotated to 
the arch. Anterior lip of the cervix was caught down be- 
tween the head and the symphysis; the posterior lip could 
not be felt. Forceps blades were applied to the head with- 
out any difficulty. With slight traction to hold the head 
steady I pushed up the anterior lip of the cervix. A slow care- 
ful extraction was then done. Circulation of the scalp as 
the head came to the perineum was satisfactory. The 
delivery was not difficult. Baby when delivered was marked- 
ly etherized and was slow in crying. He was put into hot 
water and at once began to breathe regularly; gradually 
came out of ether and soon cried lustily. The uterus acted 
well. There was a slight median tear of the perineum which 
was repaired with two silkworm-gut sutures. The baby 
weighed 7 pounds 6 ounces. I left the patient at 12 o'clock 
in excellent condition with pulse of 100. 

The baby acted well except that it had a great deal of 
mucus which necessitated constant watching. The first day 
the baby cried much and as there was no milk in the breasts 
it was put on to a modified milk of fat 2%, sugar 6%, proteid 
0.75%, no heat and no lime water, one-half ounce every two 
hours. Patient was unable to void urine twelve hours after 
delivery and so was raised up by her husband and the nurse 
on the bed pan and she then readily voided. On the morning 
of the third day the milk came in with a rush and the breasts 
became very full and hard. The nipples were slightl}^ de- 
pressed and the baby had more or less trouble getting hold 
of them. By the use of the nipple shield baby obtained 
plenty of milk and was satisfied. The morning of the fifth 
day patient's temperature was 99° and pulse 80. Evening 
temperature remained at 99° and pulse '']2. Lochia normal. 
Perineum looks well and there, is no tenderness. By the 
eighth day the baby had pulled out the nipples enough with 



CONTRACTED PELVIS. 28 1 

the use of the nipple shield so that he could be put directly 
onto the nipple. On the tenth day the stitches were removed 
and apparently a good result obtained. On the twelfth day 
temperature normal. Uterus cannot be felt above the sym- 
physis and there is no tenderness anywhere. She got up at 
the end of the eighteenth day and has done uniformly well. 
In the fifth week vaginal examination showed excellent result 
on the perineum. Slight bilateral tear of the cervix. Uterus 
normal in size and position. Nothing felt on the sides. 
Pelvic walls normal. Baby is nursing and doing well. 



282 CASE HISTORIES IN OBSTETRICS. 

Case 42. Contracted Pelvis. Elderly Primigravida. 
High Forceps. Patient is seen for the first time September 
7th. She is seven months along in her first pregnancy. She 
has been married but one year. Last menstruation came 
on January 29th of last year and therefore delivery is due 
about November 8th. She is in excellent physical condition. 
She has never been sick. She is 42 years of age. There is 
nothing of interest to note in her pregnancy. 

October 20. Measurements of her pelvis gave the follow- 
ing: Crests 27.5 cm., spines 24.5 cm., external conjugate 
19 cm. Palpation of the abdomen very unsatisfactory as 
the patient could not relax. Could not palpate any present- 
ing part in the pelvis. Vaginal examination shows very tight, 
rigid perineum. Cervix soft and partially taken up. No 
dilatation. Presenting part cannot be reached. Ischial 
spines are readily palpable. Promontory cannot be reached. 
Inclination of the pelvis normal, the pubic arch is slightly 
narrow. My closed fist can with difficulty be pushed be- 
tween the ischial tuberosities. 

October 25. The husband comes in to see me. He says 
he Is very anxious about the baby and does not want to run 
any risk of losing it at the delivery. I went over the whole 
situation with him and told him the surest way to obtain a 
living baby was to have a Csesarean section. This he abso- 
lutely refused and also he says his wife would refuse it. I 
did not urge at this time a Caesarean very strongly because 
of the fact that the pelvis was in my opinion a border line 
one. 

November i. Palpation very unsatisfactory. Probabil- 
ity is that the position is a left one. Head is movable at 
the brim of the pelvis. Vaginal examination : — Presenting 
part is readily reached and with pressure from above on the 
vertex it can be pushed down into the pelvis a slight distance. 
There is no overriding of the occiput at the symphysis. 
The promontory is not reached. The ischial spines are very 
prominent. As noted before, the outlet Is contracted slightly. 

November 2. The husband comes to the office to-day. 
I strongly advised a Caesarean section for the following 
reasons: The patient's age, 42 years, the rigid soft parts, 



CONTRACTED PELVIS. 283 

the contracted outlet. I told him frankly the baby might 
be lost and without doubt his wife would be badly lacerated. 
He absolutely refused to allow it and I then talked the whole 
situation over the next day with the patient. She also re- 
fused, being one of those unfortunate individuals who thought 
it to be her duty to suffer the trials of childbirth. She 
further refused an ether examination in order to determine 
absolutely the relation of the head to the pelvis. With a 
clear understanding of the risks she was taking for herself 
and for the baby we determined to let her go on and await 
labor. 

November 15. Pains started at 4 a.m. at intervals of one- 
half hour. At 7 o'clock the husband telephoned that his 
wife was not having any pains at all. At 9 o'clock pains 
began coming with more severity, every twenty minutes. 
Palpation at 10:30 a.m. showed the head at the brim. No 
overriding. Position O. L. A. The baby weighs about seven 
pounds. Fetal heart is best heard in the left lower quadrant, 
130 to the minute. Vaginal examination showed the cervix 
taken up and os dilated about one inch. Temperature 98.6°, 
pulse 70. She was sent at once to the hospital where she 
was to be confined. She got to the hospital about 12:30 
and then was having pains every ten minutes lasting one- 
half a minute. She was in fair labor. There was no show. 
Fetal heart remained regular at 130. Question if the mem- 
branes did not rupture just before she started from her 
home but no liquor now is draining away. During the 
afternoon she had pains only every fifteen minutes, not 
severe, [lasting but thirty to forty-five seconds. Uterus was 
relaxing well between pains. Patient's pulse had risen to 
80. At nine o'clock pains began coming every three minutes 
lasting from one to one and a half minutes. Uterus con- 
tracted very hard but relaxed well between pains. Pulse 
now 96. Vaginal examination at ten showed that the head 
was still high. Biparietal not through the brim. Definite 
caput was forming, making it certain that the membranes 
had ruptured. Dilatation of the os was three inches and 
the cervix was thin. Fetal heart now listened to every half 
hour and was found to be regular. Palpation of the uterus 



284 CASE HISTORIES IN OBSTETRICS. 

showed that it was not relaxing well between pains and the 
lower uterine segment was slightly tender. There was 
evidence of a full bladder, and she voided at once without 
difficulty. Up to now she absolutely refused all ether. 
Both she and her husband refused to let me operate. At 
twelve I told the husband that unless he would let me do what 
I thought best he would have to get another physician at once. 
Her pulse was now 120 and temperature 99°. Fetal heart 150 
and regular. Uterus was beginning to be in a tonic condition 
and the tenderness in the lower segment was increasing. 
She now consented to an operative delivery. The usual prep- 
arations were quickly completed and she was etherized and 
put in the lithotomy position, the legs held by nurses. Exami- 
ination showed the os fully dilatable. Head high in O. L. A. 
position. Large caput present. Head had not descended 
in the slightest. In dilating up the perineum which was very 
rigid, I tore the skin to the sphincter. The head was unro- 
tated. In determining the position accurately masses of 
meconium came away and a definite contraction ring was 
felt. High forceps were applied to an O. L. A. position. At 
the first attempt at application, the forceps did not lock well. 
I applied them a second time, and then obtained an excellent 
application. Fetal heart heard by the etherizer, not counted 
but very rapid. With the first tentative traction the head 
came down a little into the brim. Intermittent traction 
then brought the head to the spines without a great deal of 
difficulty. Here there was marked resistance. With much 
traction the head came further down and distended the soft 
parts. The soft parts did not stretch, but tore badly. 
Baby was finally delivered deeply asphyxiated. Cord was 
pulsating feebly. After some time the baby began to 
breathe regularly and it then cried faintly. Perineum was 
torn to the sphincter with a deep internal tear on the patient's 
right extending downwards and inwards to the spine of 
the ischium. There was another tear along the right descend- 
ing ramus which was not as severe. The patient's pulse 
was now 130 and of fair quality. A strip of sterile gauze 
soaked in 70% alcohol was packed into the vagina giving an 
excellent view of the perineum. The tear was repaired by 



CONTRACTED PELVIS. 285 

interrupted chromic catgut stitches, some buried and others 
tied in the vaginal mucous membrane. The external tear 
extended to the sphincter but in no way involved it. Three 
silkworm-gut sutures placed on the outside brought the peri- 
neum into excellent approximation. Placenta was then de- 
livered intact with all the membranes. The silkworm-gut 
sutures were now tied. Uterus acted well and there was no 
bleeding. She was then put back to bed and immediately 
upon being turned about she went to pieces. Pulse could 
not be counted at the wrist. Color was bad. There was 
no bleeding. The uterus remained hard. 

It was evident that the patient was in profound shock after 
a hard labor and a hard operative delivery. She was given 
morphia one-sixth subcutaneously at once followed by one- 
twentieth of strychnia. The foot of the bed was raised and 
she was surrounded by heaters. Pulse at once could be felt 
at the wrist but of very poor volume. She became restless. 
There was no sign of any bleeding. Morphia gr. 1/6 was 
repeated. At 2 a.m. her pulse was 120 and of very poor 
volume. She was nauseated and vomited three times before 
three A.M. Each time her pulse went to pieces but quickly 
recovered. Her color slowly improved; her legs and feet 
were warm. Gradually the pulse came down and improved 
in quality and at 5:30 it was no and volume very markedly 
improved. Her color now was fair and all nausea was gone. 
The baby except for a bruised right eye and ear is in excellent 
condition. The large caput succadeneum gives the im- 
pression of a long moulded head. 

November 16. Steady improvement, pulse 116, temper- 
ature 98.6°. Twelve hours after delivery she had not voided 
urine. There is no distension of the bladder and she has no 
inclination to void. She was perfectly comfortable without 
any distension at the evening visit and I decided not to 
catheterize her. 

November 17. This morning at two A.M. she voided six 
ounces of urine. At nine o'clock examination of the abdomen 
showed two tumors. The one on the left resilient and not 
tender and the one on the right hard and slightly tender. 
Both dull on percussion. She was catheterized and thirty- 



286 CASE HISTORIES IN OBSTETRICS. 

eight ounces of urine obtained. Pulse is 90. Temperature 
normal. The patient is in very good condition and very- 
much more comfortable than yesterday. 

November 18. Is able to lie on her side. Has voided 
several times voluntarily. Stitches look well. Slight amount 
of edema. Lochia normal and profuse. Fundus well con- 
tracted. Not tender. Baby is doing well. On the second 
day a large cephalhematoma developed on right parietal 
bone posteriorly. Patient is in first-rate condition. 

November 19. Temperature normal, pulse 78. Except 
for the hemorrhoids which appeared two days ago she is very 
comfortable. No sign of milk in the breasts. Patient is 
slightly distended. Bowels have not yet moved because of the 
severe tear. Baby is slightly jaundiced. Cephalhematoma 
has not increased in size since yesterday. For the hemor- 
rhoids a flaxseed poultice was ordered every two hours. 

November 20. Temperature 99.6°, pulse 80. Is com- 
plaining about the stitches and the hemorrhoids. Milk 
came in to-day. Breasts are full and uncomfortable. Tem- 
perature at noon to-day 101°. Pulse 88. Abdomen is nega- 
tive. Uterus not tender. Involuting well. Lochia is pro- 
fuse. Normal in color and odor. The ring of hemorrhoids 
is marked. There is considerable tenderness near the right 
ischial tuberosity with ecchymoses just below the tuberosity. 
The flaxseed poultices have given her much relief. 

November 22. Temperature dropped to normal this 
morning. Pulse is ranging from 75 to 90. The patient looks 
well. Is very much more comfortable than at any time 
previously. She complains, however, of severe pain at the 
hips and is unable to turn on either side. Pain about 
the right ischial tuberosity is very much less. Bowels were 
opened on the sixth day by a four-ounce oil enema carried 
over the fifth night. Half an ounce of castor oil was given 
early in the following morning followed three hours later by 
a glycerine enema. Abdomen is negative. Uterus is in- 
voluting well. There is no tenderness anywhere. The baby 
apparently nurses well and is satisfied and after nursing 
sleeps until the next feeding. This morning the nurse 
reported that the baby had lost five ounces since yesterday. 



CONTRACTED PELVIS. 287 

I questioned the accuracy of the weighing and asked that the 
baby be weighed before and after each feeding. After the 
second weighing it was reported that the baby showed no 
gain in weight and was crying after the nursing. Modified 
milk of the following formula, 2% fat, (>.'=i% sugar, 1% pro- 
teid, no heat and no lime water, was at once obtained for it. 
The baby was given an ounce every two hours besides nursing 
for ten minutes. It was at once seen that the mother had 
not a sufficient amount of milk in the breasts and a supple- 
mental feeding at least must be given. Jaundice has cleared 
up. Cephalhematoma is no larger. 

November 27. Stitches removed to-day. External result 
good. Given sterile water vaginal douche to-day because 
at this time lochia had a slightly stale odor. Temperature 
which had been running up to 100° at night dropped at 
once to 99°. There now is no milk in the breasts and the 
baby is entirely on modified milk and is doing well. 

Examined on the 24th day. Perineal body has healed well. 
Internal tear on her right almost healed and the result is 
excellent. Uterus normal in size and position. Cervix shows 
bilateral tear. Breasts are flabby and no milk can be 
expressed. Baby is steadily gaining on modified milk. Um- 
bilicus is healed solidly and there is no bulging. Cephalhema- 
toma is still large but is slowly decreasing in size. Patient 
is discharged to her local physician. 



288 CASE HISTORIES IN OBSTETRICS. 

Case 43. Contracted Pelvis. Posterior Parietal 
Presentation. A telephone message from my house officer 
at half -past three in the afternoon of August 13th states 
that he had just seen a primipara with small pelvic measure- 
ments, that the head which was presenting was high, that the 
membranes were ruptured, that she was in good active labor 
now, but that there was no advance of the presenting part. 
I went to the patient at once and found her, a Polander, in 
active labor, pains coming every three minutes lasting one 
minute. Between pains the uterus was soft and not tender. 
Palpation showed the firm, smooth resistance of the back on 
the left and fetal small parts readily felt on the right. The 
head is firmly engaged in the inlet and cannot be moved. 
By the fourth manoeuvre the head can be pressed but little 
further in the pelvis. There is no overriding of the head at 
the symphysis. Fetal heart is heard in the left lower quad- 
rant, 120 to the minute and regular. Pelvic measurements 
are crests 26.5 cm., spines 23 cm., external conjugate 17.5 cm. 
The baby is small, not over six and one-half pounds. 

Vaginal Examination : — Soft perineum, os uteri is fully 
dilatable but the edge of the cervix is thick. Sagittal suture 
is readily felt in the transverse diameter of the pelvis, but is 
very much nearer the symphysis than the promontory. 
The contour of the posterior parietal bone is readily felt 
curving forward from the promontory. There is marked 
overriding of the posterior over the anterior parietal bone 
and very little of this latter bone is felt. The anterior 
fontanelle is not reached nor is the posterior definitely made 
out. With two fingers in the vagina and the thumb swung 
up over the symphysis, pressure downwards with the right 
hand on the head gives no overriding at the symphysis. 
The ischial spines are readily palpated. The pubic arch 
from palpation seems to be slightly narrowed but the bis- 
ischial diameter with Williams' pelvimeter is 10 cm. The 
closed fist can be pushed between the tuberosities. No 
liquor is coming away. 

The patient's pulse is 76 and she is in excellent condition 
as is the baby. I told my house officer I saw no indication 
to interfere, that with the complete dilatation of the cervix 



CONTRACTED PELVIS. 289 

and the continued moulding of the head which it was so 
evident was taking place I thought she would deliver herself, 
that it was clear we had a posterior parietal presentation and 
as soon as the parietal bone moulded over the promontory 
the remainder of the delivery would be normal. I left the 
patient at five p.m. with the request that if she is not delivered 
by nine o'clock to let me know and to notify me at once should 
any untoward symptoms arise. 

Telephone message from the house officer at nine says 
that he had just examined the patient, that the head was 
no lower than when he examined her six hours before, that 
the lower segment of the uterus was slightly tender on pal- 
pation, that meconium-stained liquor was coming away. 
Fetal heart was 130 and the mother's pulse was 80. I got to 
the patient's house at half -past nine and as I went into the 
room it was very evident from her actions that she was well 
in the second stage of labor. The externe was just putting 
the patient in the left lateral position and as a pain came the 
anus was seen to bulge. On asking him how long that had 
been happening he said it was the first time. From the 
time the house officer left to telephone to me, to now, was not 
more than three-quarters of an hour and fifteen minutes later 
the baby was born. The baby was seen to be pale, without 
any muscular tone and the umbilical cord was collapsed. 
The externe was told to clamp and cut the cord at once and 
I took the baby to resuscitate it. (See page 478.) In the 
course of a few minutes it began to cry lustily and seemed to 
be in normal condition. There was marked overriding of 
the parietal bones twenty minutes after birth and over the 
occiput was a very large caput succedaneum. The baby 
weighed six pounds. 

Examination of the perineum by the house officer showed 
no tear to be present. The placenta came away intact a 
short while later and there was no bleeding. When I left 
the house both the baby and mother were in excellent con- 
dition. 

I was later told that the patient had a normal convalescence 
and both she and the baby were discharged on the tenth 
day. 



290 CASE HISTORIES IN OBSTETRICS. 

Case 44. Contracted Pelvis. High Forceps. My 
house officer reports the following case at eight p.m., August 
the fourteenth. A primipara, 19 years old, had just en- 
tered the hospital in labor, with pelvic measurements of 
crests 24 cm., spines 18 cm., external conjugate 17 cm. I 
saw her at once because of these small measurements. She 
says she has had slight pains since five o'clock this morning, 
that no waters have come away, and that at no time have 
the pains come oftener than fifteen-minute intervals. Her 
pulse is "ji, temperature 98.6°. 

I confirmed the pelvic measurements as reported by the 
house officer. Palpation shows vertex presentation, position 
right anterior. Head is freely movable at the brim of the 
pelvis, but by the fourth manoeuvre can be sunk into the 
pelvis. Estimated weight of the baby seven pounds. Fetal 
heart is best heard in the right lower quadrant, 168 to the 
minute. 

Vaginal examination shows a high, floating head. Cervix is 
taken up. Os is dilated one finger. With pressure from above 
on the head it was seen that the head can be sunk into the 
pelvis. There is no overriding at the symphysis. The head 
seems soft and will probably mould. The pelvic outlet is 
normal. She is a slight, frail girl with small bones. 

I decided to let her go into labor. From 9 o'clock, August 
14th, until five in the morning of the 15th she had hard pains 
every three minutes; examination then showed that the os 
is no more dilated. I told the house officer to put in at once 
a large-sized Voorhees bag. Four hours after the bag was 
put in it was pushed out and when it came out it was evident 
the membranes had ruptured. Examination then showed 
that the os was two- thirds dilated and fully dilatable. The 
patient was having slight contractions every three minutes 
but had not moulded the head down into the pelvis. The 
biparietal diameter was not through the brim. She had 
been in the hospital fifteen hours and had had twelve hours 
of hard labor, but had accomplished very little. I therefore 
decided to deliver her. Preparations for an operative de- 
livery now completed. 

Position was O. D. P. The usual technique in dilating the 



CONTRACTED PELVIS. 29 1 

perineum and cervix. With the left hand in the vagina the 
head was rotated to an O. D. A. and the right blade of the 
forceps was applied first without difficulty. The left blade 
was then applied necessitating the rotation of this handle 
about the first handle. The blades then locked readily. 
The fetal heart was heard by the etherizer. Tentative trac- 
tion showed that the forceps did not slip and that the 
head descended slightly. With gradual intermittent traction 
the head was brought to the perineum and the occiput fully 
rotated to the arch. Pressure on the scalp as the head 
came into view showed the circulation to be excellent. 
Slowly the perineum was fully dilated and the head then 
delivered. There was no difficulty in the delivery of the 
shoulders or with the body. The baby was slightly asphyxi- 
ated but soon cried. Examination of the perineum showed 
that there was no external tear but a slight internal tear was 
present. This was immediately repaired with one chromic 
catgut suture. On the fifth contraction the placenta was 
delivered intact with all the membranes. An intra-uterine 
douche of salt solution, followed by a pint of 70% alcohol 
was given. Patient was in excellent condition and made a 
good recovery from ether. The uterus acted well. 

The baby weighed 7 pounds 4 ounces. On the fourth day 
when it was weighed it had dropped to 6 pounds 5 ounces 
and was very much jaundiced. On the fifth day there was 
found a small hematoma just under the angle of the left 
jaw where the tip of the forceps had come. The jaundice 
of the baby gradually cleared up without treatment, and 
by the seventh day the hematoma had entirely cleared up. 

On the thirteenth day after delivery the patient was 
examined. The uterus was found well involuted, normal 
in position, freely movable and no tenderness in the pelvis. 
There is a stellate tear of moderate degree in the cervix. 
The tear of the perineum is well healed. There is con- 
siderable leucorrheal discharge. She is up and about the 
ward in good condition and was discharged well. The baby 
is gaining. 



292 CASE HISTORIES IN OBSTETRICS. 

Case 45. Contracted Pelvis. Cesarean Section. 
Patient has been under observation for the past three weeks 
because of the fact that she has small pelvic measurements 
and a fair-sized baby. She is 22 years of age, and is nearly 
at term in her first pregnancy. The measurements are as 
follows: Crests 25 cm., spines 22 cm., external conjugate 
17.5 cm., bis-ischial diameter 9 to 9.5 cm. 

August 6. Vaginal examination showed that the promon- 
tory could just be reached. The arch is slightly narrowed. 
The patient was etherized and the head could not be pushed 
down into the pelvic brim, and there was marked overriding 
at the symphysis. Caesarean section was advised. She did 
not accept the advice but went out of the hospital to consult 
friends. 

She entered the hospital August loth having hard uterine 
contractions. She says she has had these for three hours. 
Palpation of the head shows that it is not entering the brim 
at all, is freely movable and is overriding the symphysis. 
I again advised a Caesarean at once if she wished to obtain 
a living baby. She accepted the advice and was at once 
prepared for operation. Abdomen was shaved, scrubbed 
with soap and water thoroughly and then with alcohol 70%. 

Operation. Ether anesthesia. Ether was started only 
after the preparations were complete and the patient was on 
the operating table. A median laparotomy incision was 
made five inches long to the left of the umbilicus, two inches 
above and three inches below. Ergot was given intramus- 
cularly as the incision was made. Uterus was found free 
and no adhesions present. A walling-off gauze was placed 
on both sides of the uterus, above and below. Longitu- 
dinal incision then made into the uterus. Placenta was 
found under the incision. Incision of the uterus was enlarged 
slightly upwards and downwards. The placenta was torn 
through. Ergot now repeated. The baby, in vertex presen- 
tation, was immediately delivered and cried at once. The 
cord was clamped and cut. The placenta was removed and 
the uterine cavity wiped out with sterile gauze, care being 
taken to remove all the membranes. The uterine incision 
was now closed by two rows of interrupted catgut sutures, 



CONTRACTED PELVIS. 293 

care being taken not to include the endometrium in the deep 
stitches which were of No. 2 chromic catgut. Superficial 
sutures were of chromic catgut No. i. The sponge count was 
correct. The abdomen was closed by No. i plain catgut to 
the peritoneum; No. 2 chromic catgut to the fascia with in- 
terrupted sutures. Interrupted silkworm-gut sutures to the 
skin. Patient went off the table with a pulse of 120 in ex- 
cellent condition. She made a good ether recovery and there 
was only a normal amount of bleeding present. The baby 
weighed 7 pounds and 15 ounces. 

Her temperature the night of delivery was 101°, pulse 120. 
On the first day she had a temperature of 101.4°; pulse no. 
She was slightly distended, but on the whole was very com- 
fortable. 

Patient's bowels moved on the afternoon of the first day 
by enema. From then on she made an excellent convales- 
cence. Her temperature both morning and evening of the 
second day was 99°; pulse dropped to 90. From then on 
she ran an absolutely normal temperature and pulse. The 
stitches were taken out the eighth day and a first intention 
wound obtained. 

On the twelfth day she sat up with a head rest, and on the 
fourteenth day she was out of bed. Except for a very small 
granulating area in the middle of the scar the wound is solid 
with no bulging. She is nursing her baby and it is doing 
well. 

She was discharged on the twenty-first day, both she and 
the baby in good condition. 



294 CASE HISTORIES IN OBSTETRICS. 

Case 46. CESAREAN Section Because of Past Oper- 
ative Obstetric History. Patient presents herself at the 
hospital with the story that she has lost three children in 
two previous pregnancies. The first baby was lost after a 
long labor followed by an instrumental delivery. The 
second followed within the year and twins were lost. The 
babies at each of these deliveries were not weighed. She 
was looked after out of town and the time was so short 
before delivery was due that it was impossible to look up 
the physician who attended her. Her last period was on 
the 14th of November and she is due for delivery from the 
2 1st to 24th of August. She is a short thick-set Jewess with 
a large pendulous abdomen. She comes to the hospital with 
her husband and they both say they are anxious for a living 
child and want to have a Caesarean section done. The 
external measurements are crests 28 cm., spines 19.5 cm., 
external conjugate 18.5 cm. The arch is narrow and of the 
male type. Palpation shows a good-sized baby about eight 
pounds. Vertex presenting. Occiput left anterior. Fetal 
heart 120 to the minute in the left lower quadrant. It is 
with difficulty that the closed fist can be put between the 
ischia. The promontory can be reached without ether. 

I decided to do a Caesarean section on August 21st and she 
was told to come into the hospital on the 19th for preparation. 
She entered the hospital as requested and was given a large 
amount of water to drink, bowels thoroughly cleared out with 
castor oil and enema. On the morning of August 21st under 
ether anesthesia an incision one and one-half inches to the 
right of the median line, extending from just below the ribs 
to just above the umbilicus was made. Peritoneal cavity 
opened without incident. The uterus was found free with no 
adhesions. A walling off gauze of one long strip was then 
packed about the uterus, above and below and on both 
sides of the incision. The uterus was incised in the median 
line and the incision was enlarged slightly by tearing up- 
ward and downward. The placenta was found immediately 
beneath the incision. Placenta torn through, membranes 
ruptured, and the baby extracted by the breech. The cord 
was clamped and cut and the baby handed to an assistant 



CONTRACTED PELVIS. 295 

and as it was taken out of the operating room it cried. The 
upper and lower ends of the uterine incision were caught by 
vulsellum forceps and the uterus brought up into the in- 
cision. Placenta was delivered, the membranes peeled off 
and the cavity wiped out with gauze. There was a slight 
amount of bleeding. The uterine wound was sewed up with 
six deep No. 2 chromic catgut sutures. Superficial sutures 
were of No. i catgut. Gauze packing was removed and the 
uterus dropped back into the peritoneal cavity. Abdominal 
wall closed by No. i plain catgut to the peritoneum, and 
No. 2 chromic catgut used in interrupted sutures to the 
fascia, skin closed with interrupted silkworm-gut sutures. 
Dry sterile gauze dressing put over the wound and held in 
place by two adhesive plaster straps. Tight scultetus 
bandage applied below the incision. Sterile vulval pad ap- 
plied. Normal amount of flowing was present. Patient 
went off the table in excellent condition but with a pulse of 
130. She made a good ether recovery, vomiting but a few 
times. Pulse steadily came down in rate and late in the 
afternoon was 92 and her temperature was normal. The 
baby weighed eight pounds and four ounces. The distension 
in the late afternoon and early evening was marked. Calo- 
mel gr. 1/6 for eight doses at half-hour intervals was started 
in the early evening and a high glycerine enema was given 
her with an excellent gas result and some feces. 

August 22. Half a seidlitz powder was given early this 
morning followed two hours later by a suds enema. Excel- 
lent results were obtained. At the morning visit she was in 
excellent condition, abdomen soft and not tender. Pulse 98, 
temperature normal. Patient has voided. Lochia is nor- 
mal in amount and character. There is colostrum in the 
breasts and the baby is to be put on to-day every four hours. 

August 31. Patient has made a normal convalescence. 
Abdominal stitches were removed on the eighth day and 
the wound is solid. On August 23 the baby weighed seven 
and a half pounds and from then on it gained steadily. 

September 9. Patient sat up in bed with a head rest on 
the sixteenth day and was out of bed the next day. She 
gradually got up about the ward and went home on the 
twenty-first day after operation. 



296 CASE HISTORIES IN OBSTETRICS. 

Case 47. Contracted Pelvis. Craniotomy. Patient 
is seen for the first time about eleven p.m., August i6th, in 
response to a telephone message from my house officer say- 
ing he had just seen a rachitic dwarf who was in active labor. 
Her measurements as he made them out were intercristal 
25 cm., interspinous 22 cm., external conjugate 17 cm. He 
said she was fully dilated, the head was very high and over- 
riding the symphysis. Membranes had ruptured at seven 
P.M. She had been in labor as far as he could determine at 
least twenty-four hours. 

When I saw her she was in active second-stage labor, 
pains coming every two minutes lasting a minute and a half. 
Uterus was relaxing well between the pains. Head is overrid- 
ing the symphysis and freely movable. From a very hurried 
inspection, the patient's body from the waistline up seemed 
to be normally developed. Her legs were very short and 
marked bowing was readily seen. She is said to limp badly 
on the right leg. Vaginal examination: — Os uteri is fully 
dilated. Presenting part can just be reached. The promon- 
tory is readily felt and the symphysis shows a distinct curve 
with the convexity towards the sacrum. Definite overriding 
of the occiput over the symphysis is present. 

The patient was an Italian and her husband said it was 
her first pregnancy and that she had been having pains all 
the night before and all day, yet they had not sent for an 
externe until six o'clock this evening. I was unable to find 
out that a midwife had been in charge of the patient. The 
patient was begging for ether and I told the husband as 
clearly as I could that we should have to "take the baby" 
but it would probably be dead when born. He agreed to 
what I told him and the preparations which had been started 
were speedily completed. She was placed on the kitchen 
table, etherized and then scrubbed up. Catheterized. Per- 
ineum thoroughly dilated and the pelvis examined. The 
closed fist could not be placed between the symphysis and 
the promontory. With the fingers extended and the thumb 
drawn into the palm the hand then could be pushed through. 
The occiput was on the left. The sagittal suture in the 
transverse diameter. The head did not seem large. I deter- 



CONTRACTED PELVIS. 297 

mined in spite of the ruptured membranes to attempt a ver- 
sion as the cord was felt pulsating. With resistance on the 
fundus and the left hand in the uterus — no contraction ring 
was felt — I seized a foot and drew it down. It proved to 
be the anterior. There was no difficulty in doing the version 
until I came to the extraction of the head. Traction on the 
body combined with suprapubic pressure gained nothing. 
The cord was still pulsating and forceps with some difficulty 
were put on to the after-coming head but absolutely no 
progress made. Therefore I determined upon a craniotomy. 
The destructive set had been boiled up as I felt confident 
from the house officer's description of the case that it would 
be needed. 

The baby's body was dropped downward towards the 
floor and my assistant made firm traction on it. The Smellie 
scissors with the left hand guiding the tips were passed up 
to the occiput and with a to and fro motion of the right hand 
the scissors were forced through the lowest portion of the 
occipital bone just to the right of the middle line. The 
scissors when through the occipital bone were pushed into 
the brain substance and turned about several times after 
they had been opened. They then were brought out at 
right angles to the way they entered the skull in order to en- 
large the hole. A finger of the left hand was held at the 
opening and the solid blade of the cranioclast was passed 
within the hole with the button of the lock looking up. The 
second blade was then passed into the vagina closely hugging 
the occiput in order to avoid the anterior lip of the cervix. 
The blades were locked and then the screw-nut tightened. 
Traction then was made downward and at once much of 
the brain contents oozed out. The fingers of the left hand 
were within the vagina so that no piece of the occipital bone 
might pierce the mother's soft parts. Strong traction made 
and the head steadily came down through the brim and it was 
then slowly delivered. The cord was cut and the baby put 
aside. It was not a large baby, weight by guess not over 
six and a half pounds. The delivery was completed at 
1 150 A.M., August 17th. Patient's pulse was 120 but she was 
in a perfectly satisfactory condition. The perineum showed 



298 CASE HISTORIES IN OBSTETRICS. 

a second-degree median tear. Three silkworm-gut sutures 
were passed so that the stitches went to the base of the tear. 
At 2:15 A.M. the placenta came away intact with all its mem- 
branes. Ergot was at once given intramuscularly. A two- 
quart intra-uterine douche of sterile water was then given, 
followed by a pint of 70% alcohol. Apparently all the douche 
water returned. The interior of the uterus was not explored. 
The house officer tied the stitches in the perineum and the 
patient was then put back to bed. Her pulse steadily dropped 
and when I left was 100. Uterus was acting well and there 
was no excessive flow. She made an excellent convalescence ; 
the result on the perineum was only fair. She was discharged 
from the hospital care on the fourteenth day. 

I told the husband after the delivery that if his wife ever 
again became pregnant she would have to have a Caesarean 
section done if they wished a live baby. I carefully ex- 
plained to him what that meant and the reasons for it, add- 
ing that if she did become pregnant to put her at once under 
our care. All of which he agreed to do. 

Within a year one of the district nurses found that this 
woman was well along in her second pregnancy. She told 
the nurse that she had gone to a ''private doctor" in order 
to get good care. 

She now of course was beyond our reach. The next word 
I had of her was that her "private doctor" had attempted to 
deliver her by version, and was unable to extract the head. 
He was forced to leave the patient — body extracted but 
the head in the uterus — until he went out of the house and 
telephoned for a craniotomy set! 



Technique of Craniotomy. 

A destructive set consists of a perforator and a cranio- 
clast together with the necessary instruments needed for 
repairing the perineum. The Smellie scissors, which are 
long, sharp-pointed and strong, are as satisfactory as any- 
thing to use as a perforator. Braun's cranioclast has 
proved very satisfactory in my hands. It consists of two 
blades, one solid and the other fenestrated, the first fitting 



CONTRACTED PELVIS. 299 

into the second. The blades are held together by a button 
lock, the button being on the solid blade. The handles are 
further locked by a screwlock put into position after the 
blades themselves are placed. The cranioclast which the 
supply houses carry in stock is sixteen inches long or more, 
so long that not infrequently there is no container in the 
house in which it can be boiled. The one I carry is fourteen 
inches long and has been of sufficient length in all cases 
where I have used it and will fit into the sterilizer I carry. 
The cranioclast has but the cephalic curve. Theoretically the 
outer blade, the fenestrated one, should be placed over the 
occiput or at least in approximation to the occipital bone 
in vertex presentations so that when traction is exerted the 
normal flexion of the head is maintained. If this is remem- 
bered, it follows that in right positions the button of the 
lock looks upward while in left positions the button points 
downward. If this fact is remembered, flexion which may 
be so essential is more readily secured. 

The technique of a craniotomy is as follows: — The posi- 
tion of the patient, the aseptic technique, catheterization, 
dilatation of the perineum and of the cervix is as in all oper- 
ative deliveries. The position of the fetus is then determined, 
counterpressure is given by an assistant, trained or untrained, 
on the head through the abdominal wall. This counter- 
pressure is most important for if the head should slip up 
when perforation is attempted serious maternal lacerations 
might follow. With firm counterpressure on the head, the 
operator seizes the scalp with the double hook and pulls 
strongly downward. If an assistant is at hand he holds 
this hook as placed. If there is no assistant and good 
counterpressure is given the use of the hook is not absolutely 
essential. The closed perforator is passed into the vagina 
along the gloved fingers of the left hand until the point 
comes to the lowest part of the occiput which presents. 
Then by a to and fro motion the perforator is forced through 
one of the skull bones. The perforator is then opened and 
moved about in the brain tissue and withdrawn at right 
angles to its entrance into the skull, thus making a larger 
hole. The fingers of the left hand are kept at the hole made 



300 CASE HISTORIES IN OBSTETRICS. 

by the perforator. The solid blade of the cranioclast is then 
passed gently into this hole in the skull with the button 
looking up or down as the case may be as previously ex- 
plained. The fenestrated blade is then placed over the 
occiput and the instrument locked. As traction is begun, 
the maternal soft parts are protected from injury by possible 
spicules of bones from the fetal skull by the left hand. Steady 
traction brings the skull into view and the body is then 
delivered. The advice so commonly given of passing a 
douche nozzle into the cephalic cavity in order to wash out 
the brain^substance, I purposely have omitted as it is an 
entirely unnecessary addition to the technique. 

In craniotomy on the after-coming head the technique is 
as already given. The one point to be determined is whether 
the perforation shall be through the occiput or through the 
mouth and base of the skull. Two factors determine the 
answer: which point can be reached the easier, and which 
point is the less dangerous for the mother. In the above 
recorded case the occiput was the point most accessible for 
the perforation, and as there was no prolapse of the anterior 
vaginal wall, therefore this point was chosen to perforate. 
Some of the perforators have the sharp points curved on the 
flat and if one is using this type, care must be taken that 
the curve when the perforation is made points downwards. 
If this is remembered the possibility, if the instrument should 
slip, of doing damage to the maternal soft parts is much 
lessened. This point of course holds only when the craniot- 
omy is on the after-coming head at the occipital bone. In 
this latter condition the body is dropped downward toward 
the floor while if the perforation is to be done through the 
mouth and base of the skull the body is drawn strongly up- 
wards. In order to get the arms out of the way a sterile 
towel is passed about the body so as to include the arms as 
already described in the technique of forceps to the after- 
coming head (page 245). Whether the operator follows the 
delivery of the placenta with an intra-uterine douche depends 
upon his belief in such a procedure or not. It was given 
here because the technique of the hospital demands it. 

A craniotomy means a mistake by some one in the manage- 



CONTRACTED PELVIS. 301 

ment of the case. Careful examination of the patient as 
already advised will always tell whether a craniotomy will 
be necessary in order to deliver the patient. Among the 
ignorant foreigners with whom we have to deal in large 
hospital clinics, in order to avoid these unpleasant compli- 
cations we must obtain their entire confidence and there is 
no way so satisfactory as having well-administered pregnancy 
clinics. 

In neglected cases where the baby is dead, craniotomy is 
much the preferable operation to a hard forceps delivery or a 
version and extraction. It is not done as frequently as it 
should be because of the repulsion the family may feel on see- 
ing the mutilated baby. This, however, is no valid reason for 
not performing a craniotomy. Craniotomy on a living child 
is forbidden by the Catholic church and if a non-Catholic 
physician is operating in a Catholic family some responsible 
member of the family must be told in the presence of others 
exactly what a craniotomy consists in. No medical terms 
should be used, nothing but straightforward plain English. 
If consent to a craniotomy is not obtained and the physician 
in charge feels that it must be done, then there is nothing 
left for him to do but to withdraw from the case, unless he 
is willing to be dictated to in his management of the case. 

Summary of Contracted Pelvis. 

The preceding seven cases bring up some of the fundamental 
problems of managing cases with small pelvic measurements. 
Grouped, they show how all doubtful cases should be managed. 
All cases do not call for the same procedure ; what is indicated 
for one is unnecessary for another. In Case 46 I did a Caesa- 
rean section chiefly because of the history the patient gave. 
This patient had a contracted outlet but even if she had not, 
she had a right to ask that a Caesar can section be done in 
the light of her previous disastrous history. 

In Case 41 careful palpation showed that the head was not 
overriding the symphysis, but at the beginning of labor it 
was seen that the biparietal diameter was not through the 
brim. The prognosis here depended much on the type of 



302 CASE HISTORIES IN OBSTETRICS. 

labor the patient would have. The type of labor any given 
patient will have is unknown. Patients of the higher classes 
do not as a rule stand a hard labor as well as their less for- 
tunate sisters. This unquestionably is a fact but there are 
many exceptions to the general statement. In this case the 
labor was excellent . and steady progress was made and by 
this labor she converted what looked to be a hard operative 
delivery into a relatively easy one. 

In contrast to this case is the next one, Case 42, a forty- 
two year old primigravida. Here the membranes ruptured 
early. Pains were inefficient and dilatation was slow. 
When the pains became of good strength the uterus failed 
to relax well and became tender to palpation. There were 
signs of a beginning contraction ring. The pulse was rising, 
further delay in delivering the patient would lead to serious 
consequences and therefore operation was insisted upon with 
the recorded results. The risk this patient subjected herself 
to, because of her unwillingness to have a Caesarean section 
was much greater than she could appreciate. Her condition 
and the baby's at the present time I do not know, for I have 
lost track of them. Such hard high forceps work is bad 
obstetrics and the sooner the laity is educated to the point 
where they will understand that such work is responsible 
for much chronic invalidism in women and for a large mor- 
bidity among the children then will they accept the advice 
to have a Caesarean section done. The risk this woman 
took in being delivered from below was many times greater 
than the risk of an elective Caesarean section. 

Cases 44 and 45 show well the difference in advice given 
because of the presence or absence of overriding of the pre- 
senting part at the symphysis. At no time was there any 
doubt in my mind that the first case could be delivered 
from below without undue danger to mother or child. With 
an ether examination the latter case showed overriding 
at the symphysis. This persisted even after a short test 
of labor, and she then finally consented to a Caesarean 
section. 

In borderline cases one is] justified in allowing the patient 
to have a few, not more than five or six hours, of good labor 



CONTRACTED PELVIS. 303 

to see whether the head will go into the pelvis. Longer time 
in labor adds to the risk of an abdominal delivery. In 
cases where the test of labor is to be applied no vaginal 
examinations should be made after labor has begun. Descent 
of the presenting part should be followed by palpation or by 
rectal examinations. Many Csesarean sections have been 
done when the patients have been in labor longer than six 
hours and the reported results appear to be good. The ques- 
tion at once arises how many have been done late in labor 
with death following in a few days? These are the cases that 
physicians unfortunately do not report. 

On all doubtful cases, after careful pelvimetry, palpation 
and vaginal examination, the patient should have the ben- 
efit of an examination under ether. A physician owes 
it to his patient to do this. With the hand in the vagina 
accurate estimation of the size of the pelvis can be obtained. 
How far the occiput can be pushed into the pelvis is of great 
importance in determining whether the patient is to be 
allowed to go into labor or not. I have advisedly omitted 
discussion on pelvic malformations and new growths occurring 
in the pelvis, for if the underlying principles of careful pel- 
vimetry, palpation, and vaginal examination on normal and 
borderline cases are thoroughly studied, these unusual cases 
will be easily managed. 

In borderline cases the physician can only advise the mode 
of delivery, the responsibility lies not only with him but 
the husband and wife must help in making the decision. 
The risk to the mother and child from a hard operative 
delivery must be fully explained. That there is a risk in an 
abdominal delivery must also be told. The risk, however, of 
an elective Caesarean is nothing compared with that of a hard 
operative delivery from below, when disproportion is present. 

In recent years pubiotomy has gained a few adherents. 
The only pelvic condition in which pubiotomy should be 
an elective operation I believe to be a slightly contracted 
funnel type of pelvis. In this type of pelvis the pubi- 
otomy wound may so enlarge the pelvic girdle that future 
deliveries may be accomplished without any operation. In the 
majority of cases this operation, if done at all, should be 



304 CASE HISTORIES IN OBSTETRICS. 

reserved as an operation of necessity. In those cases where 
a slight disproportion only exists, and which are seen too 
late in labor to have a Csesarean section performed, the child 
must even then be in good condition. It has unquestionably 
a field but the field is very narrow. 

Note : — In the technique of performing a Csesarean 
section, I used the phrase ''incision enlarged by tearing up- 
wards and downwards.*' It is an unfortunate description 
of the technique used. The incision through the peritoneal 
coat into the wall of the uterus is made of the proper length. 
Then in the middle of the incision the incision is carried down 
as the case may be, either into the placenta or directly on 
to the amniotic sac. It is then enlarged downwards and up- 
wards a little way and all but the lower and upper end of 
the incision is made by the knife through the entire thick- 
ness of the uterine wall. Then it has been my habit simply 
to stretch slightly the lower and upper ends. A wrong idea 
is given to say there is any tearing of the uterine musculature. 
In those cases where it is possible, I sew the uterus up with 
the first layer of sutures buried, interrupted chromic No. 2 
catgut. The second layer goes down through the muscular 
coat of the uterus. The third layer brings the peritoneum 
over the uterus by a continuous suture over this second layer 
of sutures. Not in all cases is it possible to sew up the 
uterus in this way because the uterus is so thin, and in those 
cases deep sutures are placed down to the endometrium 
and a second line of interrupted sutures is placed between 
these deep ones. Then these two lines of sutures are over- 
sewn with a continuous catgut suture, approximating the 
peritoneal edges. In clean elective cases I do not place 
any walling-off gauze in the abdomen. The sides of the 
abdominal wall are held firmly against the uterus so that the 
greater part of the liquor escapes the abdominal cavity. 
After the child is delivered and the uterus is drawn up into 
the incision a sterile towel or gauze is placed behind the uterus 
to stop any blood from getting into the abdominal cavity. 

In no Caesarean that I have done since I left out all gauze 
packing has there been any marked distension. 



SECTION XII. 
NAUSEA AND VOMITING OF PREGNANCY. 

Case 48. Nausea and Vomiting of Pregnancy. Patient 
is seen in consultation on the afternoon of August loth, and 
the following history is obtained from her. She is about 
eight weeks advanced in her first pregnancy, having skipped 
one period and the second is just due. Her menstruation 
began when she was twelve. It appears regularly every 
twenty-eight days and lasts four days. She never has any 
pains or other discomfort from it. Nausea appeared two 
weeks ago and for the first week was annoying but she did 
not vomit. For the past week she has vomited she says 
from six to ten times a day, at no particular time. The 
nausea is marked in the morning but this passes off by noon. 
The vomiting continues throughout the day at irregular 
times until she goes to bed and gets to sleep. She is sleep- 
ing poorly, waking up frequently and when awake is very 
restless. For the last two days she says the sight and smell 
of food nauseates her and since yesterday morning has eaten 
nothing. She has taken an occasional sip of water. She 
has no headache. She has not been jaundiced. She com- 
plains of no pain anywhere except of burning in the pit of 
her stomach and she says that what she vomits is greenish 
and very bitter. Her urine burns when passed and she says 
in the past four days it has become very dark in color. Her 
bowels have moved once in two or three days. The physician 
in charge says he has tried all the usual drugs recommended 
for nausea but that they have been of no avail. 

When I saw her she was in bed but had gone there simply 
because I was coming out to see her. Up to now she had 
been up and about her home. She has very high color. 
Her lips are dry, as is her skin. Pulse 80, not high tension. 
Temperature 98.6°. Physical examination: — Breasts firm, 
areola is very dark and the glands of Montgomery very 

30s 



306 CASE HISTORIES IN OBSTETRICS. 

prominent. Heart and lungs not examined as the phy- 
sician said they were normal. Abdomen is scaphoid and 
there is no tenderness present on palpation. Kidneys are 
not palpable. Spleen not felt. Percussion of liver area is 
normal. There is no tenderness at the costo- vertebral 
angles. There is no jaundice present. Vaginal examina- 
tion : — No secretion can be expressed from the urethra. There 
is no blueness of the vagina. The cervix is soft and in nor- 
mal position. The uterus is in normal position and is dis- 
tinctly enlarged. Nothing abnormal is felt on the sides of 
the pelvis. The rectum is full of hard feces. No specimen 
of the urine was seen but the physician said at his last ex- 
amination of it two days ago it contained no albumen. The 
twenty-four hour amount is not known. 

On talking with the husband it is very evident that he is 
very apprehensive about his wife's condition and the reason 
for his worry was that his own sister six months ago, he said, 
died from the vomiting of pregnancy. He frankly admits 
that he has been talking to his wife about his sister's death. 

We told him that there was not the slightest reason for 
him to be alarmed at the present time about his wife, that 
unquestionably within forty-eight hours there would be a 
marked improvement, that he must stop worrying his wife 
and that he must not mention his sister's death to her again. 
We advised him to let us get a nurse at once and with a nurse 
in charge, his wife's condition would quickly improve. He 
agreed to have the nurse and one was sent for at once. 

The following treatment was suggested : — The patient was 
to stay in bed absolutely and to get up for nothing. Her bow- 
els were to be moved at once by a high enema of magnesium 
sulphate two ounces, glycerine two ounces, water two ounces. 
The twenty-four hour amount of urine is to be measured 
and also the amount of fluids ingested. Her diet for the 
next twenty-four hours is to be only milk, not more than 
two ounces every hour. If in the first few hours after the 
nurse arrives she does not vomit the milk she may then 
have six or eight ounces every four hours while awake. She 
is to take as much water as she can. She asked for the spark- 
ling waters and she was allowed them. The only medicine 



NAUSEA AND VOMITING OF PREGNANCY. 307 

ordered was the triple bromides 40 gr. by rectum three 
times a day. The bromides were to be kept up for but two 
days if the patient's condition improved. If she continued 
to vomit another day she was to be put on rectal feeding. 
She was to be allowed no visitors and her husband was to 
be kept out of her room as much as possible. Above all, 
the patient was confidently assured that she was not in the 
slightest danger and that in a few days she would be well 
again. She was frankly told that the nausea probably would 
not entirely stop for some weeks yet, but she was promised 
that it would not be excessive. 

August 25. A note to-day from the attending physician 
in which he said that the nurse at once gained excellent 
control over the patient and the patient began to improve 
in twenty-four hours. She ceased to worry about her con- 
dition and although the vomiting kept up for two days 
after I saw her it occurred less and less. He stopped the 
bromides at the end of two days. The acid eructations were 
very disagreeable but milk of magnesia gave the patient 
marked relief. The twenty-four hour amount of urine was 
now four pints, and the bowels moved every day by enema 
and twice a week she was given a cathartic by mouth. She 
had not vomited now for over a week and the nausea was 
but slight. The nurse was still in the household and the 
patient was now up and about. 

The further history of this case was that she went to term 
with no return of the nausea and the physician-in-charge 
delivered her successfully after a long slow labor, by forceps. 



308 CASE HISTORIES IN OBSTETRICS. 

Case 49. Nausea and Vomiting of Pregnancy. In- 
duction OF Labor. Recovery. Patient is seen in con- 
sultation April loth. The following history is given by her 
physician : — 

She is now seven months advanced in her second pregnancy. 
Her first pregnancy two years ago was terminated at six and 
a half months because of severe nausea and vomiting. The 
present pregnancy progressed without undue amount of 
nausea and no vomiting until the first week in March when 
she had a very severe attack of asthma. Immediately after 
this attack, nausea became very marked and the vomiting 
began. Until March 20th she kept down the greater part 
of her nourishment and had been out and about each day. 
From March 20th to April ist the vomiting steadily in- 
creased and the greater part of the time she was kept in the 
house, and most of it in her room. During the past ten 
days in spite of varied treatment she has grown steadily 
worse. For the past six days she has been in bed, with a 
trained nurse in attendance. Six days ago all nourishment by 
mouth was withdrawn and the patient has been on nutrient 
enemata. For three days she tolerated them well and the 
nausea and vomiting, at least, were no worse. For the past 
three days her pulse has been steadily but slowly rising. She 
has lost much weight. For the last three days she has been> 
vomiting constantly and expelling her nutrients. The vomitus 
is dark brown and of very acid taste. This morning she re- 
belled at the treatment and said she knew if she ate some 
crackers and milk she could keep them down. Against her 
physician's advice she did eat them and at once had severe 
nausea followed by vomiting. This vomiting has kept up 
since eleven o'clock until now, three p.m., almost incessantly. 
Each time she vomits she passes by rectum a small amount 
of mucus. The physician says her urine three days ago was 
normal. 

The patient gave me the same story as above related with 
the addition that since noon objects in the room are blurred 
and that the figures on the wall paper are much distorted. 
She also complains of a fullness in her head but she says it is 
not a real ache. 



NAUSEA AND VOMITING OF PREGNANCY. 3^9 

The patient is pale and anxious looking and her face is 
very thin. Her lips are dry and cracked. Her pulse is thin 
and high tensioned, 140 to the minute. (Before she knew I 
was coming out to see her it was 130.) Heart and lungs 
not examined as the physician said they were normal. Ab- 
dominal examination : Fundus is one inch above the umbilicus. 
Fetal motion is felt on her left. There is slight tender- 
ness in the left lower quadrant but no spasm. There is no 
tenderness in the epigastrium. No tenderness over the 
liver. Liver area is apparently normal by percussion. The 
spleen and kidneys are not palpable. There is no jaundice 
present. Her legs are very flabby and her skin is very dry. 
Her temperature is 99.4°. 

The steady rise in pulse, the elevation of temperature, the 
eye symptoms, the emaciation, the marked desiccation were 
all bad symptoms and I unhesitatingly advised that the uterus 
be emptied. We then talked the situation over with the 
husband. Before we began he made it very clear that 
he wanted every precaution taken for the mother's life. 
He cared not the slightest for the baby. The physician 
then told the patient of our decision which she readily 
accepted. 

The question then came up of how to empty the uterus. 
The shock of dilating and emptying the uterus under ether 
seemed to me, much too grave a risk to assume and I advised 
rupturing the membranes, putting in a Voorhees bag without 
ether and then to wait for labor. The suggestion of attempt- 
ing anything without ether was very alarming to the patient 
and so we decided to give her ether. The instruments were 
sterilized and the patient was shaved, prepared and placed 
across the bed before any ether was given her. Everything 
was ready and she was told to breathe the ether in as fast as 
she could with the hope that a primary anesthesia would be 
sufficient. She breathed as told and a beautiful primary ether 
was obtained. The cervix fortunately was soft and had from 
the previous accouchement force a bilateral tear. The bag was 
very quickly pushed by the internal os and the membranes 
ruptured. She at once began to move and came out of 
ether. The bag was dilated after she was perfectly conscious. 



310 CASE HISTORIES IN OBSTETRICS. 

The bag was in place at five p.m. and at six p.m. the uterus 
was felt to contract very slightly. The pains then began 
coming at very irregular intervals from five to twenty min- 
utes apart and lasted from five to thirty seconds. With 
each contraction of the uterus the bag was gently pulled on. 
By seven-thirty the pains were coming every ten minutes and 
lasted for nearly one minute. 

It was now evident that she was in good labor and in all 
probability would so continue until the fetus was expelled. 
The nurse pulled gently on the bag with each pain. The 
patient's pulse dropped to 120 and she was standing the 
labor well. As the physician-in-charge said he would look 
after the delivery, I withdrew. 

A telephone message from the physician the next morn- 
ing saying that the bag came out at three-thirty and forty 
minutes later the baby was born. It gasped a few times 
and then died. The placenta came away without difficulty. 
Her pulse remained 120 and she was in no worse condition 
than before the delivery. 

A month later a letter from the physician was received in 
which he said that the patient made an excellent convales- 
cence, that within twenty-four hours she began taking liquids 
without vomiting and gradually her diet was increased without 
any return of the nausea or vomiting, that she now is gaining 
weight rapidly and is up and about her home. 



Summary of Nausea and Vomiting of Pregnancy. 

The usual classification of the causes of nausea and vomit- 
ing of pregnancy, namely reflex, neurotic or toxemic, is not 
satisfactory. If all cases of this condition are regarded as a 
type of a toxemia then the treatment becomes more reason- 
able. We have all seen cases where the uterus was in ab- 
normal position and yet there has been no nausea. Again 
we have seen the highly-neurotic girl go through her preg- 
nancy with no more than the usual discomforts due to the 
increase in her size. We have also seen patients with no 
demonstrable physical or nervous abnormality show severe 
and dangerous nausea and vomiting of pregnancy. Un- 



NAUSEA AND VOMITING OF PREGNANCY. 3 II 

questionably there are different types of vomiting of 
pregnancy, but the underlying cause of practically all is a 
toxemia. 

Case 48 showed a nervous element but back of it all was 
the toxemia of faulty elimination both by the bowels and by 
the kidneys. The fundamental treatment in these cases is 
to obtain proper elimination of all the products of metab- 
olism. Williams's work on the ammonia co-efficient of the 
urine, excellent as it is, can because of the very complexity of 
the analysis never become available to the general practitioner. 
He must rely on general physical examinations to guide him 
in his management of these cases. 

A complete physical examination must first be made and 
any abnormality rectified. Deviations from the normal 
position of the uterus are to be corrected. But above 
all, elimination of the toxins must be secured. In severe 
cases, hospital care will many times aid in the recovery. 
There can be no routine treatment of these cases except the 
one and fundamental treatment of elimination. Various 
drugs will help the different symptoms, but they do not cure 
the condition. The great number of drugs recommended 
not only of the pharmacopoeia but of the patented com- 
binations all prove their inefficacy. For the gastric distress 
the various anti-acid drugs must be tried; no one can be 
relied upon. If the nervous element is prominent I have 
had the best results in large doses of the triple bromides 
forty to sixty grains every four hours for three or four days, 
gradually decreasing the dose as improvement begins. The 
simple cases promptly yield to treatment if they are put to 
bed early, fed small amounts often, of readily digestible foods 
and if a nurse of pleasing but strong personality is put in 
charge of the patient. The danger in the so-called pernicious 
type lies in the fact that we persist in delaying emptying the 
uterus too long. In these serious cases the determination 
of the ammonia co-efficient will be of aid. A high ammonia 
co-efficient however is not the absolute diagnostic sign that 
it first was thought to be. Fortunately the fulminating type 
of this toxemia is rare. In this type no matter what treat- 
ment is instituted the results almost invariably are bad. 



312 CASE HISTORIES IN OBSTETRICS. 

Until we discover the underlying cause of these toxemias 
our treatment must necessarily be largely empirical. 

Had Case 49 been put to bed earlier and more vigorous 
treatment instituted the result might have been different. 
When the consultation was called there was nothing left but 
to empty the uterus as quickly as possible with the least 
amount of shock. 



SECTION XIII. 
TOXEMIA OF PREGNANCY AND ECLAMPSIA. 

Case 50. Toxemia of Pregnancy. Induction of 
Labor. Patient is seen for the first time October i6th. 
She is the wife of a physician who has been looking after her 
himself up to the present time and had chosen no one to look 
after her at her confinement. He says over the telephone 
that she is eight months advanced in her first pregnancy. 
She is supposed to have been perfectly well up to two days 
ago when she complained of slight headache. No nausea. 
Some slight blurring of vision. Bowels slightly constipated. 
Urine a month previously had been perfectly normal but had 
not been examined since, until yesterday, when examination 
showed it to contain a large amount of albumen, some blood 
and casts of various descriptions. 

I saw her about 8 130 in the evening. She then was having 
considerable pain in the right upper quadrant in the region 
of the gall bladder running through to the back. There 
were no flashes of light before her eyes and there was no 
blurring of vision. She had no epigastric pain and no vomit- 
ing. She had within an hour been put into a hot pack 
and when I saw her was sweating profusely. Her face was 
markedly edematous. Edema of the legs and hands was not 
marked. Her last period was February loth. Palpation 
of the abdomen showed a fair-sized fetus. Fetal motion 
was felt. No edema of the abdominal wall. Temperature 
was normal and pulse 100, full and bounding. She now was 
drinking plenty of water and was not vomiting. Her bowels 
had not moved to-day. I ordered at once a high glycerine 
enema and also a teaspoonful of magnesium sulphate by mouth 
every hour for six doses. Because she was sweating profusely 
and because she had had no efficient treatment up to now I 
advised against operative delivery. 

October 17. 9 a.m. She continued to perspire freely dur- 

313 



314 CASE HISTORIES IN OBSTETRICS. 

ing the night. Her bowels have moved four times since I 
saw her. Edema distinctly less in the face. Mental condi- 
tion is satisfactory. No epigastric pain. No headache. She 
now is perspiring freely. She is drinking milk and lime water. 
In the last twenty-four hours she has passed 23 ounces of 
urine. High in color, specific gravity, 1.026. Albumen J%. 
Few normal blood corpuscles; many hyaline and fine granu- 
lar casts present. Pulse 70, high tension. Normal tempera- 
ture. 

3 P.M. She has not improved as much as I had hoped. 
The amount of urine that she was secreting was lessening. 
From nine o'clock this morning to three this afternoon she 
passed only two and one-half ounces of high-colored urine. 
Her skin was dry. She had no headache or epigastric pain. 

I then decided because she was not improving to induce 
labor by means of the Voorhees bag. When everything was 
ready she was etherized, and vaginal examination showed 
a small introitus admitting only one finger. Board-like 
perineum. I carefully dilated the perineum, but even with 
as much care as possible I tore the skin to the sphincter. 
Cervix was not taken up and not dilated. With the aid of 
a Goodell dilator dilated the cervix so that it would take 
the large-sized rubber bag readily. The bag was then dis- 
tended with water. She came quickly out of ether. One-half 
hour after she was out of ether the bag was pulled on regu- 
larly every fifteen minutes and each time a definite uterine 
contraction was caused. An hour later uterine contractions 
were felt occasionally and the bag was pulled upon every 
ten minutes. For the next two hours pains increased in 
frequency, becoming regular at every three minutes, lasting 
thirty to forty seconds. The patient was kept in blankets, 
in a flannel wrapper surrounded by hot water bags and she 
perspired freely. During the night the pulse remained good, 
80 to the minute. Uterus was contracting every three to 
five minutes and at each contraction the bag was pulled 
upon. 

At six o'clock in the morning of the i8th, it was noticed 
that the edema of the face was increasing and the patient 
noticed that it was with difiiculty that she opened her eyes. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 315 

Between quarter and half past six the pains slackened and 
became less hard. Pulse had gradually crept up and now 
was 120. I determined to deliver her and an assistant was 
sent for and at half past seven she was again etherized. 
The bag was removed. Before any examination was made 
the vagina was wiped out with 70% alcohol. The os uteri 
was then found to be four fingers dilated and was very 
soft. After the perineum was again dilated up thoroughly, 
the cervix was readily dilated manually to full dilatation. 
Position of the fetus was found to be O. L. A. Head was 
floating. Head was held by the assistant at the inlet and 
forceps applied to a high O. L. A. position. Cord was found 
down beside the head and pulsating. Blades were applied 
without pinching the cord. Etherizer verified this fact by 
listening to and hearing the fetal heart. Application readily 
obtained and with easy traction the head at once descended, 
the only difficulty being that the anterior lip held slightly. As 
soon as this resistance was overcome the head came down 
further and was delivered, the body readily following. The 
baby began to breathe regularly and soon cried. Baby was 
carefully done up in a warm blanket and put aside with heaters. 
Examination of the perineum showed a superficial tear extend- 
ing to the sphincter; two sutures of chromic catgut brought 
the body of the perineum together ex-cellently and with three 
silkworm-gut sutures placed externally the external perineum 
was brought into apposition. The placenta was delivered 
intact with all the membranes. Very small amount of bleed- 
ing took place. After the delivery of the placenta the sutures 
were tied. The uterus was not held as bleeding was wished 
for. No ergot given. She made a good recovery from 
ether. No vomiting. Pulse 100, full, high tension and 
bounding. She was given morphia gr. 1/6 every six hours. 
Croton oil 4 drops were given as soon as she was out of 
ether and four hours later were followed by a glycerine and 
water enema. At 7 p.m. the patient passed four and a half 
ounces of urine, high colored. Pulse distinctly less high 
tension, rate had dropped to 90. Patient was not vomiting. 
She was perspiring freely and fluids are to be forced. Edema 
was distinctly less. Baby weighed five and a half pounds and 



3l6 CASE HISTORIES IN OBSTETRICS. 

is being treated as a premature baby and has been put on 
a weak modified milk formula. 

October 19. Temperature this morning normal. Pulse 
100. Slept fairly well last night. Her skin is moist. Bowels 
have moved twice since last visit. Since seven last night 
to ten this morning she passed thirteen ounces of urine. It 
is stained by the lochia. Edema of the face is still present. 
Milk has been given her every four hours, five to eight ounces 
as she wished it. She was ordered a tablespoonful of mag- 
nesium sulphate. Morphia continued. 

Evening visit. Temperature 99° and pulse 90, still full 
and bounding. Patient is bright and happy. Edema of 
the face distinctly less. Bowels have moved four times 
during the day. Since the morning visit she passed more 
than twenty ounces of urine as some was lost with the move- 
ments. Lochia is normal. Uterus is well contracted and 
not tender. There is no milk in the breasts. Morphia is 
stopped. 

October 20. Temperature normal. Pulse 84. Lochia 
normal, stitches look well. Slept seven hours last night. 
Bowels moved this morning by suds enema. Urine is in- 
creasing in amount steadily. Edema is much less, prac- 
tically none of the legs and very little of the face. 

Evening visit. Temperature 99°, pulse 78. Has had an 
excellent day in every respect. She is becoming hungry and 
wants something more than milk. Is to have soft solid 
diet from now on. The blankets and flannel wrapper were 
omitted to-day. 

October 21. Temperature this afternoon 98.8°, pulse 80, 
distinctly lower tension and less bounding. Urine is now 
about forty ounces in amount each twenty-four hours. So 
much lochia is present that its color is not determined and 
has not yet been examined. 

October 26. Has made an excellent convalescence. Is pass- 
ing seventy ounces of urine, light in color. Albumen 0.2% 
by Esbach's test. Sediment shows many hyaline and fine 
granular casts with renal elements adherent. Many large 
and small round cells. No blood. Occasional leucocyte. 
There has been no milk in the breasts and the baby is doing 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 317 

well on modified milk. The patient is gradually being 
allowed more and more freedom in her diet, but as yet has 
had no meat. 

November 12. The patient got out of bed the twenty-first 
day. From then on she gradually got about and made a 
steady gain. Vaginal examination to-day. Excellent result 
on the perineum. Bilateral tear of the cervix, slight on her 
right, marked on her left. Uterus is well involuted, normal 
in position and freely movable. No tenderness in the pelvis. 

She still persists in having varying amounts of albumen 
with casts in her urine and I advised her to see an internist 
for the care and treatment of her nephritis. This she did. 
Eight months after the delivery she still showed a nephritis 
and the internist felt that the condition would never entirely 
disappear. 



3l8 CASE HISTORIES IN OBSTETRICS. 

Case 51. Toxemia of Pregnancy. Induction of 
Labor. Patient presents herself at the office September 
26th. She is in the seventh month of her first pregnancy. 
Up to the present time she has been looked after by a physi- 
cian in another city. She has always been a well woman. 
Her last period began on February 23rd making delivery 
due about the first of December. Except for marked nausea 
which began at the sixth week and lasted for three months, 
pregnancy has been perfectly normal. Her blood pressure 
is 120 mm. of Hg. Examination of the urine on September 
28th showed the color to be normal, reaction acid, specific 
gravity 1.002, no albumen, and no sugar. Sediment not 
done. 

October 21. She telephones to-day that she has a slight 
headache and has noticed that her wedding ring the last 
few days was a little tight and that her feet were swelling. 
I saw her at once. She has no epigastric pain. Occasion- 
ally she has thought her eyesight was blurred. Blood 
pressure 120. Slight edema of the hands and feet. None 
of the face. Temperature normal, pulse 72. She was at 
once put onto a strict milk diet. She was told to take at 
once half a teaspoonful of salts every half hour for six doses. 
This evening she was told to take a hot tub bath and then 
to be covered up with blankets in order to sweat. The urine 
at this time was found to be high in color, acid, specific 
gravity 1.020, albumen a very slight trace, no sugar. Sedi- 
ment shows a few hyaline and fine granular casts. No 
blood. Few small round cells and vaginal detritus. 

October 22. She perspired freely after the hot bath last 
night. This morning has no headache and swelling of her 
hands is less. No blurring of the eyesight. Blood pressure 
120. Bowels have moved five times since last note. She is 
to take enough magnesium sulphate to obtain three or four 
movements each day. No change in the diet. 

October 31. She has been seen every day since the last 
note and is in excellent condition. No edema of the face, 
hands or legs. In the past week she has had an occasional 
slight headache for an hour or two during the day, usually 
in the frontal region. She is passing three pints of urine. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 319 

It contains the slightest possible trace of albumen. Specific 
gravity 1.016. Sediment shows a rare hyaline and fine 
granular cast, few round cells, occasional leucocyte, much 
vaginal detritus. No blood. Her blood pressure has not 
been over 120. To-day she is to have cereal, toast and 
crackers added to her diet. 

November 2. She vomited, this morning, her breakfast 
which consisted of oatmeal, a piece of toast and a glass of 
milk. She had no headache, no epigastric pain and there 
was no edema present. Blood pressure was 132. She was 
absolutely comfortable when I saw her with no untoward 
symptoms except the rise in blood pressure. Urine was re- 
maining at three pints and no change in the analysis. She 
was put back to an absolute milk diet. 

November 5. She has had no headache, no vomiting and 
no untoward symptoms since the last note. Her blood 
pressure has not been over 120. Cereals and toast again 
added to her diet. 

November 7. She saw an oculist to-day to see if there is 
any condition in her eyes which might cause her headaches 
as they now come only after reading or sewing. The ocu- 
list, however, found nothing wrong in her eyes. 

November 13. She has been seen every day and a speci- 
men examined every other day and there has been no change 
in her condition until to-day. Blood pressure at no time 
had been over 120. Husband brought in a specimen to-day 
from the twenty-four hour amount ending this morning. 
Amount 26 ounces. Color high, specific gravity 1.026, large 
trace of albumen. Sediment the same as before with the 
addition of a few normal blood corpuscles. I saw her at 
noontime and found her with a pulse of 90. Blood pressure 
142. Complaining of a severe frontal headache. Edema 
present in the hands and legs but none of the face. No 
epigastric pain. No flashes of light before her eyes. Skin 
is dry. She has voided no urine since 7 a.m. and cannot 
void any now. Her bowels have not moved to-day. 

She was sent at once to a private hospital. As soon as 
she arrived there she was given a glycerine and water enema 
with excellent result and then given a hot tub bath for 



320 CASE HISTORIES IN OBSTETRICS. 

twenty minutes. She was put into a flannel nightgown and 
between blankets, and surrounded by hot-water bottles. 
She very quickly began to perspire freely. Her pulse re- 
mained of good quality. She was again put on an absolute 
milk diet and water forced. 

When I saw her again at six p.m. her skin was moist, her 
headache was less and she had passed 7 ounces of urine, since 
she was in the hospital, in four hours. The Epsom salts 
which had been given her in teaspoonful doses every half 
hour for six doses had given two large watery movements. 
She has responded well to treatment and there is no indi- 
cation to interfere. 

November 14. She had a fair night. Blood pressure is 
140. Less headache, less edema over the hands and none 
over the tibiae. Since she entered the hospital, in eighteen 
hours, she has passed fifty ounces of urine, light in color, 
specific gravity 1.012, slightest possible trace of albumen. 
Sediment the same, but no blood. 

November 17. Has had no headache and is bright and 
feeling very well. She has had a hot bath once a day and 
her skin has been very active without being surrounded by 
heaters. She objects to sleeping in blankets and to-day they 
were taken away. Is passing from forty to sixty ounces of 
urine daily. Bowels are well open. Blood pressure 130. She 
is to have cereals, toast, and crackers from now on, besides 
her milk and is to sit up in a chair surrounded with blankets 
this afternoon. 

November 21. For the past two days she has been up 
and dressed about the hospital. She has done consistently 
well since the last note. She is very anxious to go home and 
as she has no untoward symptoms I agreed. 

November 24. She has been seen each day since she went 
home. Blood pressure has been 130 each time. Urine has 
been seen each day and it has shown no marked variations 
from the previous analyses. The husband came into the 
office this morning and brought a specimen. He reports that 
last night she was awakened by a headache, but within a 
short time it went away and she went to sleep again. When 
she waked this morning it was again present and more 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 321 

severe. Examination of the specimen showed a trace of 
albumen, specific gravity 1.012. Sediment of the same 
characteristics, but the number of casts much increased. 

I advised the husband to take her to the hospital at once 
and to have labor induced, and told him that the risk of 
carrying her along any further was much greater than the 
risk of induction of labor, that in all probability a live baby 
would be obtained. This he agreed to at once and went home 
and brought his wife to the hospital. As soon as possible 
after entrance she was prepared. Preparations for inducing 
labor by means of the Voorhees bag were completed and the 
patient etherized. Vaginal examination showed the head in 
the pelvis; cervix soft and partially taken up; one finger 
could be put through the internal os. Large-sized Voorhees 
bag put in very readily at 1:10 p.m. In doing it the mem- 
branes ruptured, but very little liquor came away for the 
bag was quickly dilated. The tube was tied and the vulval 
pad put in place. She was put back to bed and covered with 
blankets and surrounded by heaters. Very little ether was 
used. At 1 150 she complained of a pain and the first con- 
traction was noted. Contractions then came at ten-minute 
intervals of fifteen to thirty seconds duration. With each 
pain the bag was pulled upon. Pains steadily became harder 
and at five o'clock were coming every two minutes and 
lasted one minute. Fetal heart remained regular at 150 in 
left lower quadrant. Uterus was relaxing well and patient 
was in excellent condition. Blood pressure 140. Shortly 
after five she suddenly complained of a terrific headache 
and at once began to hold onto her head. She was perspir- 
ing freely. She had no epigastric pain, no blurring of vision 
and no flashes of light. Her pulse at this time was 100. 
Except for the headache she was in excellent condition. 

I advised that she be delivered at once, because of this 
severe headache. Her husband readily consented as did the 
patient and preparations were hurriedly completed. Ether 
was started at 5 130. The bag was removed and the patient 
then scrubbed up. The vagina was carefully washed out 
with 70% alcohol. Os uteri was found nearly three quarters 
dilated but was thick. Perineum was thoroughly dilated. 



322 CASE HISTORIES IN OBSTETRICS. 

The cervix was then dilated manually as much as possible. 
Position O. L. A. Patient was catheterized but only a few 
drops of urine obtained. Forceps readily applied to an inter- 
mediate head. On the first traction the head came down and 
met the resistance of the cervix. Considerable traction 
needed to overcome the cervix, but as soon as the cervical 
resistance was overcome, the remainder of the delivery was 
effected without difficulty at 6:20 p.m., November 24th. 

Baby breathed at once and in a few moments began to cry. 
Cord was clamped and cut at once and the baby carefully 
done up and put aside in a warm place. 

Examination of the perineum showed slight internal tear 
on the left and a deeper one on the right. No external tear. 
Tears at once repaired with chromic catgut sutures. Patient's 
pulse was now 140, but of good quality. She fortunately was 
bleeding rather freely, and as she was in good condition, I 
determined not to check the bleeding at once. On the sixth 
contraction the assistant expelled the placenta. Bleeding 
then at once stopped. Pulse after the placenta was delivered 
was 130. Cervix was not examined. She made an excellent 
recovery from ether and at eight p.m. had a pulse of 114. 
Blood pressure was no. At ten p.m. the patient had a 
temperature of 101.4° and a pulse of no. Blood pressure 
120. Skin was moist. She had slight headache, but was 
clear mentally and had no untoward symptoms. 

November 25. Temperature 99°, pulse 108 this morning. 
Blood pressure 120. Has absolutely no headache. Voided 
urine this morning with the help of a high, large hot enema. 
Baby is in excellent condition and is to be weighed to-day. 
Forceps marks are very clear, one behind the ear. and the 
other over the right eye and forehead showing that I placed 
the second blade too far forward. Patient is on a milk 
diet only. She was ordered to-day an ounce of castor oil. 

November 26. Temperature 99°, pulse 90. Uterus well 
contracted. Lochia normal. She voided the past twenty- 
four hours thirty ounces of urine besides some which was 
lost. Has no headache. Blood pressure 120. She is now 
having gruels in addition to milk. 

December 5. Has made an excellent convalescence. Tem- 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 323 

perature, except the night of the fourth day when it was 101°, 
has been normal. The highest the pulse has been was 108. 
At no time has the uterus been tender and it is involuting well. 
Lochia is still red. It has been difficult to get an uncon- 
taminated specimen of urine. Examination of one to-day 
showed a trace of albumin, but this is due to the presence of 
blood from the lochia. A few casts were found. 

Temperature on the fourth day was undoubtedly due to 
the appearance of milk in the breasts. The baby up to this 
time had been on a modified milk, but then was put on the 
breast and nursed well. The baby weighed at the first 
weighing seven pounds and fifteen ounces. It is nursing 
regularly and well. Forceps marks have nearly disappeared. 
The patient now is having a soft solid diet. Her bowels are 
moving daily with licorice powder in the evening, followed 
by an enema in the morning. 

December 15. She began her leg exercises on the twelfth 
day and to-day sat up out of bed. Is in excellent condi- 
tion and is to go to her home to-morrow. 

December 30. Has had at intervals a slight bloody vag- 
inal discharge so that she has had to wear a napkin the 
majority of days since she left the hospital. She is feeling 
well, is nursing the baby and is taking entire charge of her. 
Baby now weighs 9 pounds and 2 ounces. 

Vaginal examination shows no bulging of anterior or 
posterior wall on straining. Perineum is well healed except 
on the left where there is a small granulating area the size 
of a pea which bleeds readily when touched. The uterus is 
normal in size and position and is freely movable. There is 
a well-marked bilateral tear of the cervix with some erosion 
of the lips. If the cervix is touched with forceps it bleeds 
at once. 

This bloody vaginal discharge undoubtedly comes from the 
bilateral tear and the resulting endocervicitis and with local 
treatment much help can be given her, but as she lived some 
distance out of town and it is difficult for her to leave the 
baby long enough to come in for treatment, I advised her 
to take plain warm water douches twice a day. Two weeks 
later she reports by telephone that she now has only a slight 



324 CASE HISTORIES IN OBSTETRICS. 

leucorrhea and considers herself perfectly well. A speci- 
men of urine which she sent in the next day showed the color 
normal, reaction acid, specific gravity 1.029. Albumen ab- 
sent by the nitric acid and by the heat test. Sediment : — No 
blood or casts seen in two slides. Few leucocytes and much 
vaginal detritus. 



I 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 325 

Case 52. Toxemia of Pregnancy. Low Forceps. 
Patient is seen for the first time June 24th. She is now ad- 
vanced eight months in her first pregnancy. Her last men- 
struation began on October 26th. It was normal in every 
respect. Her menstruation began when sixteen years of 
age and comes every twenty-eight days. She has severe pain 
the first two days which necessitates her going to bed. She 
has always been well and has never been in bed with any 
serious sickness. She had been looked after, up to the present 
time, by an out-of-town physician. There has been milk 
in her breasts for the last four months and so much is now 
present that she has had to wear pads of absorbent cotton 
to protect her clothes. She will be due for delivery the 
week of August 8th. Palpation to-day shows a fair-sized 
baby lying in the left position. The head is at the brim and 
freely movable. Fetal heart in the left lower quadrant, 120 
to the minute. Measurements of the pelvis show crests to 
be 30 cm., spines 24 cm., external conjugate 20 cm. She 
was told to measure her 24-hour amount of urine and to bring 
in a specimen as soon as possible. Blood pressure is 120 mm. 
of Hg. 

July 2. Sent in a specimen from the 24-hour amount 
of urine, which is just under one quart. Analysis shows it 
to be high in color, acid, 1.028, albumen absent, sugar absent. 
She was told at once to drink enough water to pass at least 
three pints of urine. 

July 9. She reports that she is now passing three pints 
of urine and bowels are moving well every day. 

July 24. She reports that she has been having a headache 
for the past two days and that objects are slightly blurred. 
I saw her as soon as possible and found her with a pulse of 
80, rather full and bounding. Her eyelids were slightly 
puffy. She is not having any spots in front of her eyes. 
No flashes and there is no epigastric pain. No edema of the 
ankles or of the wrists. Headache she says is more frontal 
and is present all the time even at the moment she 
wakes up in the morning. Her blood pressure is 150. Speci- 
men was obtained. She was ordered a teaspoonful of Epsom 
salts every half hour until her bowels moved. Told to take 



326 CASE HISTORIES IN OBSTETRICS. 

a hot bath and to go to bed at once and then to cover herself 
up well in order to sweat profusely. She Is to have only a 
milk diet with large amounts of water. Examination of 
the urine showed it to be normal in color, specific gravity 
1.020, slightest possible trace of albumin by nitric acid and 
by heat. Sediment shows a rare hyaline and fine granular 
cast and a few round cells. Occasional leucocyte and vaginal 
epithelium. 

Telephone message from her to-night saying she is much 
more comfortable. Bowels have moved freely and headache 
is less and she says she can see better. 

July 25. Blood pressure this morning 140. Has no head- 
ache. Face is not so edematous. During the night per- 
spired freely. Had five movements. Milk diet continued. 

July 26. Improvement is marked and she looks very 
much better. The skin is moist. Blood pressure is 134 
and she has absolutely no headache. Has had no vomit- 
ing and she can see perfectly well at the present time. 
Twenty-four hour amount of urine to-day four and three- 
quarters pints, analysis of which was pale in color, acid, 
specific gravity 1.006, slightest possible trace of albumin by 
nitric acid. Sediment : — Very rare hyaline cast seen. She is 
to be up and around the house to-day. I added to her diet 
to-day cereals and toast. 

August I. Telephone this morning saying she Is having 
a slight headache. Feels nauseated but has not vomited. 
Saw her at once. Since the last note she has been perfectly 
well. Has had no headache. Bowels have moved well 
and she says her urine has been sufficient in amount and of 
light color. Face is not edematous but there is slight edema 
of the ankles and of the hands. Blood pressure 144. Skin 
is moist. Her headache at the present time is right sided 
and not in the frontal region as before. Her bowels have 
moved well by Rochelle salts every morning. She was told 
to take a hot bath at once and to go to bed. Bowels are to 
be kept more freely open by small doses of Epsom salts. 
This afternoon she had no headache and could see perfectly 
well and apparently Is in very much better condition. Blood 
pressure 132. Vaginal examination shows the biparietal 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 327 

diameter through the brim. Promontory cannot be reached. 
Cervix is flush with the vaginal vault but the os is not dilated. 
Right ischial spine is very prominent. The left is not. The 
arch of the symphysis is normal. Contour of the pelvis 
is normal. Ischial tuberosities 10 cm. with Williams's pel- 
vimeter. Perineum is thick and rigid. She is to get up to- 
morrow if the present improvement continues. Milk diet 
is continued. 

August 9. From the above date to now she has been per- 
fectly well. No headache. Bowels have been moving well. 
Urine at no time has been less than three pints. Her diet 
was gradually increased to soft solids. At 8 p.m. husband 
telephoned that his wife has been having a few indefinite 
pains. He was told to take her at once to the hospital. 
The hospital was notified to determine first if she were in 
labor. If she were not in labor to let her sleep and not to 
prepare her. 

August 10. Six A.M. hospital telephoned that the patient 
had been having pains the last half hour at ten-minute inter- 
vals lasting thirty seconds, that there were sharp contrac- 
tions, that they now had begun her preparation. From six 
until seven she had good hard pains every ten minutes, but 
they then stopped entirely. I saw her at quarter past nine. 
She was having no pains. Temperature was 98.6°, pulse 
was 76. Blood pressure was 130. Palpation of the abdomen 
shows a large baby. Back is on the left. Fetal small parts 
readily made out on the right. Head is well engaged in 
the pelvis and by the fourth manoeuvre it is seen that the 
head is well flexed. Uterus is soft and fetal heart is 120 in 
the left lower quadrant. At 11 a.m. pains began coming 
every ten minutes. This rate continued until two o'clock 
when the pains began coming every seven minutes and 
lasted from three-quarters of a minute to a minute and a half. 
Vaginal examination showed the perineum very rigid. 
The head was on a level with the ischial spines. The os 
was dilated two inches, but the cervix was thick. 

From three until half past six she had hard pains every five 
minutes lasting one minute. Fetal heart remained at 120. 
Palpation from above showed that the head could not be 



328 CASE HISTORIES IN OBSTETRICS. 

reached. Uterus was relaxing well between pains. At 6:30 
palpation of the abdomen showed that the uterus was still soft 
and relaxing well. A full bladder was very evident and she 
then voided fourteen ounces of urine. She refused any ether 
up to the present time. Her pulse at this time had risen 
to 90. Membranes ruptured at 6:30. At 7:30 she began 
to bear down and there was the very slightest possible bulge 
of the perineum. Fetal heart remained at 120. At eight 
o'clock she was given obstetrical ether with much relief. 
From eight to nine she had pains every two minutes lasting 
one minute and with each pain the perineum bulged a little, 
but there was no material progress. At nine I determined to 
deliver her. She was placed in lithotomy position. The usual 
aseptic precautions were taken. She was catheterized and 
considerable amount of urine withdrawn. When the labia 
was separated the head was in sight. The perineum was 
thoroughly dilated. It was noticed that the occiput rotated 
from an O. L. A position to full rotation and back again to 
O. L. A. several times. I could not reach an ear and there- 
fore put on forceps to the sides of the pelvis, being guided by 
the sagittal suture and the posterior fontanelle. Cervix not 
seen or felt as it was behind the head. A slow easy extrac- 
tion of a large head then done. Circulation of the scalp 
remained satisfactory and when the perineum was thor- 
oughly dilated the head was carefully delivered. The anterior 
shoulder was brought to the arch, the shoulders coming 
down in the left oblique diameter and the baby was born 
at 9:25. Cord stopped beating almost at once and was 
clamped and cut and the baby put away. At 9 42 the pla- 
centa came away intact spontaneously on the seventh con- 
traction. Immediately followed a gush of bright red blood. 
The uterus was hard. Examination of the perineum showed 
there was a slight median external tear. The bleeding was 
so free that I took a sterile gauze pad, soaked it in 70% 
alcohol and placed it at once in the vagina and held it in 
place. The nurse held the uterus down hard onto the pad. 
At this time pulse was no and she was in good condition. 
Uterus was remaining hard and with pressure from below 
by the sterile pad the bleeding gradually stopped. At ten 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 329 

o'clock her pulse was 120 and she looked badly. She was 
not restless and was not vomiting. She was breathing well 
and there was no great amount of bleeding at the present 
time. The gauze packing was taken out of the vagina a 
few minutes after ten and from then on there was only a 
slight amount of oozing. Perineum then repaired with two 
silkworm-gut sutures. The uterus had a tendency to relax 
and she was given ergot intramuscularly. Uterus held in 
turn by myself or by my assistant and gradually the bleeding 
entirely stopped. Her pulse stayed at 120 until eleven 
o'clock and from then on it gradually came down. At half 
past eleven the rate dropped to 100 and the volume im- 
proved. She stayed absolutely quiet, was not restless and 
was breathing well. The uterus did not bleed although it 
still had a tendency to relax. At one she had a pulse of 90 
and the uterus was hard and well contracted. Blood pressure 
was 100. She took some broth at one o'clock which was 
repeated again at half-past one. The baby weighed eight 
pounds and eleven ounces and was in excellent condition. 
I left her at half past one. There was no bleeding and the 
uterus was hard. Pulse 90, of fair volume and tension. 

August II. Temperature this morning normal, pulse 80. 
Has voided and except for tenderness over the fundus is in 
perfectly satisfactory condition. Lochia normal. 

August 12. Temperature 98.6°, pulse 80. Uterus is at 
the umbilicus, well contracted, secondary tumor is present, 
just below the fundus. Nurse says however that six hours 
ago she voided ten ounces of urine. Patient was asked to 
void again and when she was voiding nurse pressed down 
immediately over the secondary tumor and she passed 
twelve ounces of urine, but there still was a small tumor 
present. It is quite evident that the bladder is not entirely 
empty. 

August 13. Temperature 99°. Pulse 80. Baby is nurs- 
ing every two hours and is satisfied. There is still a second- 
ary tumor in the abdomen. She is unable to empty her 
bladder completely. The uterus is hard and is still at the 
umbilicus. Not tender. 

August 17. Temperature and pulse continue normal. 



330 CASE HISTORIES IN OBSTETRICS. 

Except for the fact that the uterus has gone down very slowly 
and IS still only a finger breadth below the umbilicus, she is 
making a perfectly satisfactory convalescence. She now is 
able to empty her bladder completely. 

August 20. Stitches removed to-day and apparently a 
good result obtained. Baby is nursing regularly and appar- 
ently is satisfied. 

August 31. Patient began her exercises on the fourteenth 
day and they did not increase the lochia. She got out of bed 
today and is doing well. Tomorrow she is to walk around the 
hospital and although she looks badly I can find nothing ob- 
stetrically wrong. 

September 8. She goes home today. Has steadily im- 
proved and for the past week has been on regular hospital 
diet. 

September 16. Vaginal examination made to-day shows 
excellent result on the perineum. Cervix has a very slight 
bilateral tear. Uterus in normal position and very small; 
freely movable. Nothing on the sides. There is a slight 
brownish discharge present at the cervix, but she does not 
have to wear a pad. Baby is doing well. Umbilicus is 
healed. Movements of normal characteristics. 

She was asked to send a specimen of her urine to the 
office. Examination of this specimen showed it to be nor- 
mal in all respects. Both patients are discharged well to 
their own physician. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 33 1 

Case 53. Toxemia of Pregnancy. Contracted Pel- 
vis. Cesarean Section. Patient is seen in consultation 
December 24th in answer to a telephone message from a 
physician saying that he had a patient with a marked ky- 
phosis, who in the last forty-eight hours had developed a 
large trace of albumin, that she was getting very edematous 
but that she had no headache. I saw her at once with him 
and got from her the following history: She is within two 
weeks of term in her first pregnancy. She has been under 
observation for the past month and the first thing wrong that 
the nurse noticed, was five days ago when the right leg was 
slightly swollen. The nurse thought nothing of it but the 
next day she noticed that the left leg was also swollen. There 
was no swelling of the hands. Yesterday the physician saw 
her and found a large trace of albumin in the urine. She 
was at once put to bed and put on a milk diet. When I 
saw her she was not complaining of pain anywhere. No 
headache. She thought her face was slightly swollen. 
Examination shows the patient to be a typical rhachitic 
dwarf. The abdomen is so pendulous that it touches her 
thighs for a distance of nearly five inches below the groins, 
where there is maceration of the skin. Her pelvic measure- 
ments are intercristal 22 cm., interspinous 21 cm., external 
conjugate 17 cm. Palpation shows a fair-sized baby lying 
in a right position. Fetal heart is in the right lower quad- 
rant 120 to the minute. There is no edema of the abdominal 
wall. There is present marked edema of the feet, ankles 
and legs up to the knees. No edema of the hands. Very 
slight edema of the face and eyelids. Patient had a normal 
temperature, pulse of 80 and a blood pressure of 160. Vaginal 
examination: No edema of the vulva. Fair-sized introitus. 
Head is readily reached. Promontory cannot be reached. 
Symphysis is broad. Pubic arch is narrow and of the male 
type. The outlet is slightly contracted. Closed fist can 
just be pushed between the ischial tuberosities. The head 
can be pushed down into the pelvis. 

She has had no proper treatment and I decided to watch 
her for twenty-four hours and to institute efificient treatment. 
She was ordered put into a hot bath for one-half hour 



332 CASE HISTORIES IN OBSTETRICS. 

and then to be put to bed and covered with blankets in 
order to induce sweating. She has been drinking not more 
than two or three glasses of fluid during the day and has 
been passing a very high-colored urine with about one-half 
per cent of albumin. It is not known what the sediment con- 
tains. She was urged to drink more water. Her bowels have 
not been moving well. They were to be opened by divided 
doses of Epsom salts. A strict milk diet was insisted upon. 

The question of how to deliver this woman was gone over 
with the physician, and I felt at this time that the question 
was more in the action of the markedly pendulous uterus 
rather than the contraction of the pelvis. I thought that the 
baby could probably come through the given pelvis; but 
the probability was that when she started in labor the uterus 
would push the head directly against the promontory rather 
than down into the pelvis. Should she push the head by 
the inlet I felt that the remainder of the delivery would look 
after itself. 

December 25. Physician telephones that the patient had 
vomited this morning and was a little more edematous and 
that in the past twenty-four hours she had passed 24 ounces 
of urine. I saw her at 11:30 and found that the blood 
pressure had risen to 170. She was having some slight frontal 
headache. Inspection of the vulva showed that the edema 
had increased tremendously. So much so that it was scarcely 
possible to get one finger in the vagina in order to examine 
her. At the home where I saw her it was impossible to look 
after a seriously sick woman and so I brought her at once into 
the Lying-in Hospital and the physician on duty allowed me 
to look after her after he had seen her with me in consultation. 

The edema had increased so much that it was very evident 
that if we were going to do the delivery from below we 
would get very severe tears and that probably with the 
amount of edema present it would be almost impossible to 
deliver her without a craniotomy and we both agreed that a 
Caesarean section was the safest procedure for the mother 
and undoubtedly the safest for the baby. Examination of 
the urine passed before operation shows it to be high in color, 
acid, specific gravity 1.020. Albumin one-half per cent. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 333 

Many fine granular and hyaline casts. Some with blood 
adherent. Many large and some small round cells. 

After much delay the patient gave permission f or a Caesarean 
section. She was then scrubbed up and prepared for operation. 
She was etherized at eight o'clock and a median incision was 
made just to the right of the middle line five inches long. 
The abdomen was opened and a considerable amount of 
free serous fluid escaped. Uterus found to be in very marked 
lateral torsion. The right Fallopian tube was almost at the 
median line. An attempt was made to right this torsion but 
it was unsuccessful. Walling-off gauze placed in the abdomen. 
The uterine incision was made in the median line of the abdo- 
men but it was clear that when the uterus recovered from the 
torsion this incision would be well to the right of the median 
line. Incision five inches long. Placenta found beneath 
it. Placenta torn through, the amniotic sac broken and 
the baby delivered without incident. It was much ether- 
ized. Placenta was removed intact, but the membranes 
were very strongly adherent and required considerable wip- 
ing off with gauze to free them. Small amount of bleeding. 
It was now seen that there was a large amount of free fluid 
present in the abdominal cavity. The uterus was sewn up 
as before described. Uterus acted well. Gauze removed. 
Peritoneum closed with continuous plain catgut suture. 
Fascia was sewn with interrupted chromic catgut No. 2 and 
skin incision closed w^ith double-headed silkwgrm-gut sutures. 
Patient went off the table with pulse of 130 in fair condition. 
Baby was readily resuscitated and it weighed six pounds 
and eight ounces. Patient was at once put between blankets, 
a flannel nightdress put on and surrounded by heaters. 

December 26. Temperature this morning 100.2°, pulse 115. 
No vomiting. In excellent condition. Abdomen soft. Is 
taking small amounts of liquids. Has voided once but the 
urine was so contaminated with the lochia that it was not 
examined. Her skin is moist and she has perspired freely 
all night. Temperature to-night 98° and pulse 84. 

December 27. Temperature 98.8°, pulse 108. Is voiding 
urine freely. Distension this morning is noticeable but 
there is no vomiting. Is taking liquids well. Edema of the 



334 CASE HISTORIES IN OBSTETRICS. 

face is distinctly less. She was ordered .a glycerine enema 
with two drams of turpentine and from it obtained an excel- 
lent result of gas. Temperature to-night 98.6°, pulse 120. 
Distension is very distressing. There is no more tenderness 
in the abdomen than is usual after a section. Enemata fre- 
quently repeated give the patient much relief for a few hours 
but the distension then reappears. 

December 28. Temperature stays normal. Pulse this 
morning 112. Slept fairly well. Were it not for the disten- 
sion she would be very comfortable and in excellent condi- 
tion. This morning she was given half a compound cathartic 
pill every half hour for four doses. Four hours later a glycer- 
ine enema obtained an excellent result. 

December 29. Temperature 99°, pulse 108. Distension 
much less. Very little tenderness in abdomen. Urine has 
been passed with enemata and no accurate account of the 
amount kept. To-day specimen was light in color, specific 
gravity 1.015. Albumin slight trace. Sediment shows a 
few casts, hyaline and fine granular. No blood. Milk is 
coming into the breasts and the baby is being nursed regu- 
larly. Edema of the legs is still present. 

December 30, Temperature 98.6°, pulse 72. In excellent 
condition; distension much less. No tenderness in the 
abdomen. Patient is now on soft solid diet with much milk. 

January 2. Is steadily improving. Temperature and 
pulse normal. Edema almost entirely gone. 

January 6. Abdominal stitches out to-day. First inten- 
tion wound. Scar solid. Baby is being nursed regularly 
and is doing well. Urine to-day showed a very slight trace 
of albumin. Few hyaline and fine granular casts present. 

January 10. Patient up in a chair for half an hour to-day. 
She is in excellent condition. She is now on regular house 
diet without meat. 

January 16. Vaginal examination: — No edema of the 
vulva, nulliparous cervix. Uterus well involuted and appar- 
ently not adherent to the abdominal wall. No flowing. 
Urine shows the slightest possible trace of albumin and no 
casts seen. She is discharged to her own doctor for obser- 
vation of her kidneys. Baby has done consistently well and 
is also discharged. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 335 

Case 54. Eclampsia. Vaginal Cesarean Section. 
This patient was brought to the hospital November twenty- 
fifth by friends with the following incomplete and unsatis- 
factory history. She is seven and a half or eight months 
along in her second pregnancy. The first pregnancy ended 
in an early miscarriage. The friends say she was perfectly 
well up to two days ago when she complained of headaches 
which have steadily become more severe. It is probable 
that she had a slight convulsion just before being brought 
to the hospital. While she was being prepared for examina- 
tion by the house officer she had a severe convulsion. The 
physical examination shows slight puffiness of hands and 
face, slight pitting of the ankles. Heart sounds loud and 
thumping. No murmurs heard. Lungs negative. Palpa- 
tion of the abdomen shows the uterus to be a hand's breadth 
below the ensiform. Fetal motion is seen and felt. Vaginal 
examination shows the cervix undilated and not taken up. 
Blood pressure is 240 mm. of Hg. Examination of the urine 
showed it to be smoky in color, to contain one half per cent 
of albumin, not enough to take the specific gravity, hyaline 
and fine granular casts with blood and renal elements pres- 
ent. Pulse 100. Temperature 98.6°. 

I determined to deliver her at once by a vaginal Caesarean 
section. She was prepared, etherized and placed in lithotomy 
position. The baby was delivered by version and was alive. 
It weighed four pounds and twelve ounces. The patient 
went off the operating table with a pulse of 130 in good con- 
dition. Her blood pressure immediately after delivery was 
no. While she was under ether her stomach was washed 
out and an ounce of a saturated solution of Epsom salts 
left in the stomach. She was placed between blankets and 
surrounded by heaters. Gradually her blood pressure in- 
creased and three hours after delivery it was found to be 
150. She was at once bled eighteen ounces and her blood 
pressure dropped to 90 and her condition greatly improved. 

November 26. She had a fair night. She was given 
enough morphia to keep the respirations down to twelve per 
minute. Blood pressure this morning 160. She is perspir- 
ing freely. She is conscious but not yet clear and well 



336 CASE HISTORIES IN OBSTETRICS. 

oriented. She has as yet passed no urine. Bladder is not 
distended. Uterus is well contracted and not tender. Her 
pulse is 102. Temperature 99.6°. She is drinking water 
freely and having salt solution six ounces every four hours 
by rectum which she is absorbing. Blood pressure to-night 
130. 

November 27. Bowels moved yesterday and in the 
afternoon she voided urine which was lost. There is no 
vomiting and she is retaining the salt solution by rectum. 
Blood pressure has not been over 130 all day. Temperature 
to-night 99.8°, pulse 88. The amount of urine the patient 
is passing is unknown for it is lost with the movements. She 
is clear mentally. She is drinking much water and taking 
from four to six ounces of milk every four hours. Morphia 
stopped this morning. 

November 28. Temperature this morning 99°, pulse 82. 
Slept well all night. She complained of very slight headache. 
Blood pressure 150. Her estimated amount of urine is suffi- 
cient and it is much lighter in color than before delivery but 
as yet it has not been examined because of the lochial con- 
tamination. Temperature to-night was 98.8° with a pulse 
of 80. Bowels are moving freely by divided doses of salts. 
The baby gradually failed and died to-day. This evening 
patient began to complain of severe headache and became 
listless. Blood pressure was found to be 180. She was at 
once bled thirteen ounces. The blood pressure dropped to 
130. Within an hour the untoward symptoms cleared up. 

November 29. Blood pressure 130. In excellent condi- 
tion. Breasts are not filling up. Lochia is normal. Milk 
diet continued. 

December i. The patient to-day showed a positive cul- 
ture of diphtheria and she was transferred to the South De- 
partment of the Boston City Hospital. 

Here she made an excellent obstetrical convalescence and 
as soon as negative cultures were obtained she was dis- 
charged well. Unfortunately this patient has not been 
examined since the operative delivery. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 337 

Case 55. Eclampsia. Palliative Treatment Followed 
BY Vaginal Cesarean Section. January ii. Patient is 
seen shortly after eleven a.m. to-day in consultation with 
the family physician who gives the following history. The 
patient is about seven and one-half months advanced in her 
second pregnancy. Five days ago she began to have a slight 
headache but as this was not unusual for her she said noth- 
ing of it. She continued having headaches and two days 
ago had slight nausea and vomited twice. She was seen at 
this time by her physician who regarded this nausea as an 
attack of indigestion and treated it accordingly. The urine 
at this time was not examined. Yesterday afternoon her 
headache became very severe and at this time she had a 
convulsion. She was at once taken to the local hospital. 
She was given one-sixth of morphia subcutaneously and ten 
minims of veratrum viride. The veratrum viride was re- 
peated every four hours for two more doses. From the 
time she entered the hospital shortly after three p.m., Jan- 
uary loth until one a.m. this morning she passed seventeen 
ounces of urine. She regained consciousness about four p.m. 
and since then she has been clear mentally and with but 
slight headache. 

She has been covered since entrance with blankets and sur- 
rounded by heaters. She has had two drops of croton oil. 
This was followed in two hours by a suds enema from which 
was obtained a large result. 

When I saw her she was bright and smiling. She did not 
look sick. She has no headache, epigastric pain or flashes 
before her eyes. Her face is flushed and evidently edema- 
tous. Her pulse is 80, full and bounding. She is perspiring 
freely. She answers my questions quickly and well. No 
material difference in the history is obtained. She says she 
remembers nothing from shortly after noon yesterday until 
sometime early last evening. 

Physical Examination : — Heart not enlarged ; no mur- 
murs present. Aortic second sound is very sharp. Lungs 
negative. Fundus of the uterus is three fingers breadths 
above the umbilicus, — small baby lying in a right position. 
Fetal heart is heard in the right lower quadrant, 130 to the 



338 CASE HISTORIES IN OBSTETRICS. 

minute. Her skin is moist. There is slight edema of her 
face, hands and lower legs. Blood pressure is i8o. Vaginal 
examination: — No edema present. Cervix is undilated and 
uneffaced. External os admits one finger. Vertex is freely 
movable above the brim. 

Since one this morning to noon, she has passed seven 
and a half ounces of urine. The specimen I saw was high in 
color and contained a trace of albumin. 

I advised induction of labor by means of the Voorhees bag 
as the safest procedure for the mother, with the probability 
of obtaining a living baby, but added that it was doubtful 
if it would live any length of time. The patient was a 
Catholic and was much averse to the induction of labor as 
was her husband. 

Against delivery were the facts that she had been nearly 
twenty-four hours without a convulsion, that her bowels were 
moving well, that she was sweating profusely, that she had 
no subjective symptoms and finally, in all probability al- 
though the baby will be born alive and can be baptized it 
will not live to grow up. For delivery are the following 
points: she has had one convulsion, the amount of urine is 
decreasing, the edema is not decreasing, the blood pressure 
is high in spite of elimination treatment and veratrum viride. 

The danger to the mother and to the child should she have 
more convulsions was carefully explained to the husband. 
Both the husband and the wife chose to take the added risk 
for the sake of the baby with the hope that palliative treat- 
ment would tide her over the present emergency. I agreed 
to this with the full understanding that they assume the 
risk and it was not my advice. 

A flannel nightgown was put on the patient and she was 
to be kept between blankets and surrounded with hot water 
bottles. Three times a day added efforts were to be made 
to induce sweating. She was ordered veratrum viride ten 
minims by mouth every four hours and if pulse drops to 
60 to stop it. Milk and water only to be given her. 
The twenty-four hour amount of urine to be measured and 
also the amount of fluids ingested. Bowels to be moved 
freely by divided doses of Epsom salts. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 339 

January 13. Telephone from the physician this morning 
saying that yesterday the patient had had a good day, that 
she had voided in twenty-four hours twenty-eight ounces of 
urine and that her bowels had moved five times but that 
this morning she was complaining of a headache and that it 
steadily was getting more severe; she had passed but six 
ounces of urine in the past ten hours and that the edema had 
increased. I advised him to give her at once one-quarter of 
morphia subcutaneously and to prepare her for delivery as 
soon as possible. 

I arrived at the hospital at noon. The patient is clear 
mentally. The edema of the face and hands has increased. 
She is complaining of terrific frontal headache. No flashes 
before her eyes and no epigastric pain. Blood pressure is 
180. She has voided no more urine and the bladder is not 
distended. Her bowels have moved three times. She has 
not vomited. The husband and patient agreed at once to 
delivery and as preparations were completed she was at once 
etherized. The operating room was very warm and the 
patient covered with blankets. Lithotomy position. Peri- 
neum dilated. Cervix admitted two fingers and on attempt- 
ing to dilate it, it was found to be very rigid. I at once 
abandoned the idea of combined mechanical and manual 
dilatation and decided upon vaginal Caesarean section. 
This was quickly done. The only difficulty was that I did 
not at first find the line of cleavage between the bladder 
and uterus. As soon as this was developed the remainder of 
the operation went smoothly as I had taken with me an 
assistant. The baby was lying in the right posterior position. 
With the left hand the occiput was rotated anteriorly and 
forceps were then readily applied. Delivery was accom- 
plished without difficulty. The baby was alive and weighed 
on estimate about five pounds. It was at once put into hot 
water, after clamping and cutting the cord, and it soon began 
to breathe regularly and then to cry. It was given to a 
nurse who oiled it at once and did it up in absorbent cotton. 
Heaters were put about it. During the delivery the patient's 
blood pressure dropped to 160. There was practically no 
bleeding and ten minutes after the delivery of the baby the 



340 CASE HISTORIES IN OBSTETRICS. 

placenta was expressed. Even then there was no bleeding. 
The incision in the anterior uterine wall was at once repaired 
and she went off the operating table with a pulse of no 
in excellent condition. Before she came out of ether her 
stomach was washed out and two ounces of a saturated solu- 
tion of Epsom salts left in. Before I left she was out of ether 
and was sweating profusely. She was restless and was given 
morphia gr. i/6 subcutaneously. 

January 14. Telephone this evening from the physician 
saying that the patient in the first twelve hours after delivery 
had passed fifty ounces of urine. The edema had become 
much less. She had no headache. Temperature was nor- 
mal and pulse 80. Bowels had moved and she was in ex- 
cellent condition. The baby was alive and was taking milk 
well from another mother. 

January 18. Saw the patient this afternoon. She has 
made an excellent convalescence. There is no edema of 
the face, hands or legs present. The patient is bright and 
cheerful. Her blood pressure is 132 mm. of Hg. The breasts 
are full and hard. They have been massaged three times a 
day with hot camphorated oil. She has been given a tea- 
spoonful of Epsom salts morning and night and has had two 
to three watery movements each day. She is passing from 
fifty to sixty ounces of urine but it has not been examined as 
it is contaminated with the lochia which is still profuse. 
The baby is not doing well. He is on a weak modification of 
milk but it does not agree with him. I advised that the 
salts be stopped and the mother's bowels be moved by licorice 
powder or cascara and an enema if necessary each morn- 
ing. I suggested that the breasts be pumped out with the 
English breast pump every two hours and to use this milk 
for the baby. Up to now the patient has been on a liquid 
diet. Her diet is to be gradually increased daily with due 
regard to the conditions of the urine. 

January 24. Telephone to-day from the physician and 
he says the patient has gone along splendidly without any 
setbacks. The baby steadily lost ground and died on the 
twentieth. 

April 10. The patient comes to my office to-day. She 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 34 1 

says she is feeling steadily stronger and now considers her- 
self perfectly well. Her eyes bothered her considerably for 
some weeks after the delivery but now since she has had 
different glasses they are very much better. She has occa- 
sional headaches. Blood pressure is 130. Specimen passed 
in the office showed slightest possible trace of albumin. 
No casts found. There was not enough to obtain the specific 
gravity. Vaginal examination shows a slight bulge of the 
anterior vaginal wall on bearing down, and a slight tear of the 
perineum. Scar of the vaginal Caesarean is solidly healed, 
no induration or tenderness present. Uterus is normal in 
size and position. Cervix shows a stellate tear present, due 
to the former bilateral tear and the recent vaginal Csesarean 
incision. There is no tenderness in the pelvis and no vaginal 
discharge present. She asked about the advisability of 
going through another pregnancy and I told her she must 
wait six months at least after it is known that the urine is 
normal in all its characteristics. 



Summary of the Toxemia of Pregnancy and Eclampsia. 

The six preceding cases show typical histories of the 
toxemia of pregnancy. They show well what careful over- 
sight of a pregnant woman will accomplish in warding off a 
threatening eclampsia (Cases 50, 51 and 52), and how desper- 
ately sick a woman who has no sufficient care during preg- 
nancy may become (Cases 53, 54 and 55). The symptoms 
present in these cases are the usual ones that appear in tox- 
emia of pregnancy. Headache is generally the first to mani- 
fest itself. Blurring of vision, flashes of light before the 
eyes and epigastric pain usually come later. The pain that 
Case 50 complained of in the region of the gall bladder I 
regarded akin to the epigastric pain as there were no physical 
signs present to explain it in any other way. Coincident 
with headache often is found edema of the hands and face. 
In fact it is not at all] uncommon to find edema before the 
headache appears. Edema of the feet and legs of itself is 
not an untoward symptom as this usually is due to the ob- 
struction to circulation on account of the enlarging uterus. 



342 CASE HISTORIES IN OBSTETRICS. 

A return of nausea and vomiting in the latter part of preg- 
nancy after it has completely disappeared must be always 
regarded with great suspicion. Had the physician so re- 
garded it in Case 55 and not simply as an attack of "indiges- 
tion" he might, and not without hope, have carried this 
patient along to term without further development of the 
threatening eclampsia. Every pregnant patient who devel- 
ops a headache must be treated as developing a toxemia of 
pregnancy until the most searching examination proves that 
it is not so. Careful analyses of the urine will show gen- 
erally the beginnings of the toxemia. All pregnant patients, 
as already stated, should have their urine examined at least 
once in two weeks the last three months of pregnancy. If 
the routine advised in the hygiene of pregnancy were 
strictly carried out in all cases, the number of cases of 
eclampsia would be greatly decreased. A physician who 
has several cases of eclampsia develop in his practice each 
year is not doing careful work. This means one of two 
things: either he does not impress upon his patients the 
importance of care during pregnancy, or he does not appre- 
ciate the early signs and symptoms of an impending toxemia. 
It is quite evident the physician in charge of Case 50 did 
neither. If such a physician will not look after his own 
wife better than he did, what is the care worth which he 
gives his patients? 

These are the clinical symptoms and signs that every 
physician must be able to interpret and act promptly upon. 
Not all physicians own a blood-pressure apparatus, yet no 
physician who attempts to look after obstetric cases should 
be without one, any more than he should attempt to practice 
medicine without a stethescope. The average blood pressure 
in a normal pregnancy is 120 mm. of Hg. and a steady rise 
is indicative of a toxemia. Very rarely are symptoms of a 
toxemia present without a rise in blood pressure. All of 
these cases showed it. In Case 50 the instrument was not 
used as it occurred before the present available ones were on the 
market. Occasionally one finds a patient with nothing on phys- 
ical examination, but a high blood pressure, from 180 to 200 
mm. of Hg. The risk such a patient runs in being allowed to 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 343 

go on in her pregnancy, if by treatment it cannot be reduced, 
is great and the sooner she is dehvered without undue shock 
the better it is for her. There have not been a great number 
of such cases reported as yet, and the best way to meet this 
condition is not agreed upon, but the risk such a patient runs 
is very great and one never rests easily until she is delivered. 

The treatment of toxemia of pregnancy is without a ques- 
tion, elimination. To be of use the treatment must be 
vigorous, the more marked the symptoms the more urgent 
the need of elimination. But do not think for one instant 
that because the symptoms one moment are mild that they 
will so continue. Toxemia of pregnancy is the most treach- 
erous disease there is, and when all apparently is progressing 
smoothly something will happen, we do not know what it is, 
— a convulsion follows — or one after another comes and 
the patient dies. A patient with a toxemia of pregnancy 
must be regarded as a dangerously sick woman. The reason 
for so regarding her, is because we know so little about this 
disease and because the treatment which appears efficient 
in one case is absolutely without avail in the next. 

Elimination is obtained by the bowels, the urine and by 
the skin. All three means must be used. Except in the 
mildest cases the patient should be put to bed. Even in 
mild cases when the rise in blood pressure is twenty or thirty 
millimeters, then bed should be insisted upon. If the patient 
is put to bed in a flannel nightgown between blankets the 
skin becomes much more active. 

There is no better cathartic for causing watery movements 
than magnesium sulphate in divided doses. The objection 
to this medicine is that many patients vomit it. The bowels 
must be thoroughly opened and if one drug will not accom- 
plish it others must be quickly tried. Enemata to empty 
the lower bowel should always be given at first. Four ounces 
of glycerine given with a rectal tube is excellent. If the 
patient is unconscious after a convulsion, then croton oil two 
to four drops in sugar or butter placed on the back of her 
tongue may be given or elaterin gr. i/6 subcutaneously. 

Diuresis is best obtained by the forcing of large amounts 
of water. One word of caution must be given here. If the 



344 CASE HISTORIES IN OBSTETRICS. 

patient is edematous this edema must be reduced before 
water can be forced. If she is edematous, salt solution under 
the skin must not be given, but if no edema is present then 
it may be given as rapidly as it is absorbed. If it is given 
under the breast the technique must be perfect, for infection 
following the giving of salt solution is a very serious error. 
Many times it may be given just as efficiently by the rectum 
without the added risk of infection. Many times I have 
irrigated, with salt solution or if this was not at hand plain 
hot water, the rectum and colon as far as the rectal tube will 
reach by means of two tubes before the patient has come out 
of ether after delivery. By doing this the lower bowel is 
thoroughly emptied and therefore more prepared to absorb 
the salt solution. 

I have noticed it to be a clinical fact that in some cases, 
if large amounts of water are forced, not infrequently the 
blood pressure will remain elevated, even although elimina- 
tion is apparently sufficient. In such cases the amount of 
fluids ingested must be restricted. 

Diaphoresis before delivery can be obtained by a hot tub 
bath. If there is any cardiac complication this means must 
not be used. The same may be said of the hot wet pack 
or of the hot air bath. I practically never use the hot air 
bath and only very ^rarely the hot wet pack, for if patients 
will not perspire covered with blankets and surrounded by 
heaters it has been my experience that they will not with the 
other means. Pilocarpine must under no circumstances be 
given to these patients for it is a much too dangerous drug 
to use. 

These are the means to produce elimination whether before 
the delivery or after delivery. If one does not believe in 
the emptying of the uterus in serious toxemic cases or when 
actual convulsions occur it will be unnecessary for him to 
master the details of the various operations used where the 
immediate emptying of the uterus is demanded. There is 
a wide difference of opinion in regard to the immediate 
emptying of the uterus when convulsions have occurred. 
Some excellent physicians in this country and abroad favor 
the palliative treatment. Other equally able men demand 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 345 

that the uterus be emptied as soon as a convulsion occurs. 
Each set of physicians report recoveries from both methods of 
treatment, the palHative and the operative, and one who has 
been so fortunate as not to meet many cases of eclampsia 
does not know what to believe. The truth of the matter it 
seems to me is that we all are groping about in the dark, hop- 
ing to find out the fundamental cause of eclampsia and then to 
treat it rationally. Unquestionably the best authorities are 
agreed that the treatment of the toxemia of pregnancy, 
whether we know its underlying cause or not, is elimination. 
If this treatment is to be effective it must be vigorous from 
the first sign of toxemia that occurs. If improvement fol- 
lows and the troublesome symptoms disappear, no question 
of emptying the uterus will arise. Case 51 is an excellent 
example of attempting to carry a patient along to full term 
with a toxemia present. The mistake, if one can call it a 
mistake, in this case, was in allowing the patient to go home 
the first time from the hospital. The reason I allowed 
her to do so was that she was so very unhappy at the hospi- 
tal and that she said she would carry out to the letter my 
orders. It was a risk to take but not a grave one. The 
toxemia became more marked and then the question was 
whether to palliate or to induce labor. I am confident in 
such cases where the improvement is variable it is much 
safer for the mother and baby to empty the uterus before the 
toxemia runs to an eclampsia. If any one can tell what 
any given toxemic case will do the next twenty-four hours 
then we could say what treatment had best be carried out, 
but no one can. It is a disease of the greatest uncertainty. 
We know it is a disease caused by the pregnant condition, 
hence it is rational from our present knowledge, or lack of 
knowledge, to terminate the pregnancy because of our uncer- 
tainty of what each succeeding day may bring forth. If 
the untoward symptoms do not clear up under efficient 
treatment, then empty the uterus before the patient has a 
convulsion. At the present time, the most efficient way to 
induce labor with the least amount of shock is to place a rubber 
dilating bag within the os uteri. Cases 50 and 51 were 
started up in labor this way. There is practically no shock 



346 CASE HISTORIES IN OBSTETRICS. 

in the deliveries carried out in this way. Both made excellent 
convalescences and both children lived. This method very 
rarely fails to start up labor, especially if the tube of the bag 
is pulled upon regularly. 

Packing the cervix and vagina with gauze or the insertion 
of bougies in the uterus after rupture of the membranes have, 
in my hands, given very unsatisfactory results and now I 
never resort to their use. 

If you cannot start up labor and you are certain the patient 
should be delivered, other means must be considered. Either 
dilatation of the os uteri by the hand or by a mechanical 
dilator, or one of the cutting operations must be resorted to. 
The shock from manual or instrumental dilatation not infre- 
quently is alarming. The tears that come from a hurried 
divulsion may be extensive and death may occur, in reality 
from the hemorrhage of a ruptured uterus, but if an autopsy 
is not obtained the cause often is recorded as eclampsia. 

If the patient about to be delivered is a multigravida, many 
times a manual dilatation can successfully be done without 
undue shock. The same is true of some primigravidae. 
Whether a given cervix will dilate readily or not is always a 
problem. In Case 55 the cervix felt as if it would dilate 
readily, yet when the patient was under ether and an at- 
tempt made to do it manually it was very rigid. I then did 
a vaginal Caesarean section without difficulty. In a primi- 
gravida with the cervix uneffaced and the os uterus undilated, 
some kind of a dilator must at first be used until two fingers 
can be pushed through the os uteri. The mechanical dilators 
are powerful instruments and in any but the most careful 
hands, extensive lacerations may be caused. Even in the 
most careful hands lacerations of the cervix will at times 
take place, but if slow dilatation is obtained and not a rapid 
divulsion the results will be good. 

The objection common to all mechanical dilators is that 
dilatation takes place from outside when nature dilates the os 
uteri from the inside. By this means nature Is in no way 
imitated, while with the Voorhees bag the process is much 
akin to nature, but the progress obtained by this method is 
sometimes slow. 



-J 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 347 

Vaginal Caesarean section is where the cervix and anterior 
uterine wall, after the latter is freed from the bladder, is cut 
sufficiently so that the child in the uterus can be delivered 
without further tearing of this incision. It is not an operation 
for the tyro to attempt. It may be very difficult and the 
damage possible to the mother's organs by careless operating 
is too great to subject the woman to. The shock from a 
vaginal Caesarean section is very slight. It can be done 
rapidly. At times the bleeding from the lower uterine 
sinuses may be severe, but if not excessive, such bleeding in 
eclampsia is to be desired. 

In the past few years many writers have advised delivering 
eclamptic patients by an abdominal Caesarean section. In a 
few well picked cases I believe Caesarean section is permis- 
sible. One dislikes to place an added strain on organs already 
somewhat damaged. Unquestionably the kidneys in eclampsia 
are damaged by the toxin and a further strain may be the 
turning point of the case. In Case 53, Caesarean section was 
done not by election but by necessity. The difference is 
great. If by necessity we are forced to do something which 
under other conditions would be unjustifiable and obtain a 
good result, are we then justified by a few such cases, to rec- 
ommend for the treatment of eclampsia in all cases as an 
elective operation a procedure which we recognize carries 
with it an added risk to the patient already dangerously ill? 

The patient delivered, the after treatment is as important 
as the delivery itself. A patient delivered is by no means 
out of danger. A great gain has been made. Careful nurs- 
ing now is essential. No patient with eclampsia should be 
delivered at home unless efficient nurses can be had. The 
hospital is the ideal place for the eclamptic patient. Unless 
the patient has the means to command all the necessities for 
the efficient treatment of this condition, the physician must 
insist that she go to a well-equipped hospital. 

As the treatment before delivery was elimination, so it is 
after delivery. To the treatment already advised, bleeding 
may be added. If the patient continues to have bad symp- 
toms after delivery, with a high or rising blood pressure, then 
bleed her. Case 54 shows well the value of such treatment. 



348 CASE HISTORIES IN OBSTETRICS. 

Within a few days I have seen a patient who had had some 
six or eight convulsions before delivery and ten hours after 
delivery began again to have them. In the next twelve 
hours she had fifteen convulsions. I saw her have two in 
rapid succession and advised that she be bled at once. 
Twenty- five ounces were withdrawn from the median basilic 
vein. The blood pressure dropped from 165 to no. She 
became quiet, her pulse though rapid, 120, was good. In 
about eight hours she became conscious. She had no more 
convulsions and from then on made an excellent convales- 
cence. This is not an exaggerated picture of the effect of 
bleeding the patient. The same picture was seen in Case 
54, but not so marked. The objection to bleeding is the 
lowering of the patient's power of resistance to infection. 
The objection to bleeding before delivery is the same plus 
the added danger of an operative delivery. One does not 
know how much blood will be lost at the delivery and if the 
patient has only very recently, a few hours before perhaps, 
been bled, this added loss of blood may be sufficient to kill 
her. I have never bled a patient before delivery and I know of 
no published series of cases where this has been tried out. 

Combined with the eliminative treatment goes the giving 
of morphia subcutaneously in sufficient amounts to bring the 
respirations, at least, to ten per minute. Gradually as the 
hours pass after the delivery is over, and the patient*s con- 
dition improves, the amount of morphia given is diminished. 
Drugs have little effect on the lowering of the blood pressure. 
As the toxin is eliminated the pressure gradually falls. If 
it stays up for some weeks after delivery and the urine fails 
to clear up, then permanent damage of the kidneys must be 
suspected. (Case 50.) 

The diet in these toxemic cases should be milk only for 
at least forty-eight hours after delivery. If then the patient 
makes a steady improvement, gruels and soft solids may be 
added ; with each addition of food the urine and the patient's 
general condition must be watched. 

Eclampsia and placenta praevia are the two most fearful 
obstetric complications which a physician must meet. The 
latter is an accident and the physician has no control over it. 



TOXEMIA OF PREGNANCY AND ECLAMPSIA. 349 

In too many cases the former is due to ignorance or wilful 
neglect on the part of the physician. Carefully watched 
patients with whom the hygiene of pregnancy has been gone 
over and who do what they are told rarely develop eclampsia. 
They will develop in spite of efficient care slight degrees of 
the toxemia of pregnancy. Rarely will such cases go on to 
convulsions, for if the treatment is efficient the symptoms will 
disappear, and if they do not, the patient should be delivered 
before a convulsion occurs. Unfortunately this cannot always 
be accomplished and in spite of the most careful watching 
and treatment a few patients will have convulsions. The 
risk a patient runs in being carried along further in pregnancy 
while a toxemia is present is real, but how great the risk is 
no one knows and we have as yet no accurate way to deter- 
mine what this danger is. 

Babies of eclamptic mothers often do poorly, many are 
premature, and not a few are lost in the delivery. I believe 
all eclamptic babies should be given a teaspoonful of castor 
oil shortly after birth in order to get rid of all possible absorp- 
tion of the toxin that may be present. An eclamptic should 
not be allowed to nurse her baby unless she rapidly recovers 
from her illness. The reported deaths of babies shortly after 
nursing from eclamptic mothers makes one question the 
advisability of allowing a baby to nurse its mother when 
an eclampsia has been present. Even because of these few 
reported deaths, striking cases as they were, I am not ready 
to say that all eclamptic mothers should not nurse. I have 
seen many babies nurse from mothers who have had eclamp- 
sia, with no bad results. If the eclamptic symptoms rapidly 
disappear with proper eliminative treatment, I can see no 
reason why the baby should not nurse. As an added safe- 
guard I now pump out from the breasts the first of the milk 
that appears and do not give it to the baby. After this milk 
is withdrawn, and if there are no further contra-indications, I 
then allow the babies to nurse. 



SECTION XIV. 

FACE PRESENTATION. 

Case 56. Face Presentation. Chin Posterior. In- 
ternal PoDALic Version. My house officer reports the 
following facts: — That he has just examined a patient with 
a face presenting, that all his attempts to flex the head are 
unavailing and that he wanted me to see the case with him. 
I saw the patient at once. She is a Jewess, at term in her 
fourth pregnancy; the three previous labors were all normal. 
Labor began at nine this morning, the '* waters" came away 
at ten o'clock and she sent for an externe shortly after. The 
externe found nothing abnormal until his second vaginal 
examination about three p.m. when he made the diagnosis of 
a face presenting. When I saw her at four the patient was 
having pains every three minutes which lasted a minute to 
a minute and a half. The uterus was soft and relaxed well 
between pains. On palpation nothing definite was made out 
because of the fat abdominal wall. Fetal heart was regular, 
at 150 to the minute in the left lower quadrant. The house 
officer said it had been 120 an hour previously. Vaginal 
examination confirmed the findings of the externe and house 
officer. The irregularities of the face were readily felt and 
the chin was found posteriorly in the right oblique diameter. 
The OS uteri was fully dilated. The head was small and it 
was not firmly engaged in the pelvis. I readily flexed the 
head by pressure upward on the brow while with my right 
hand I pressed in and downward on the occiput. The 
moment pressure on the brow was lessened the face again 
presented. As the fetal heart had increased in rate I 
again listened to it and found it to be very irregular. I 
therefore advised the patient to take ether and let us deliver 
her. She accepted the advice. As soon as preparations 
were completed the patient was etherized. The perineum 
had been badly lacerated from previous deliveries and dila- 

351 



352 CASE HISTORIES IN OBSTETRICS. 

tation was accomplished very quickly. The left hand was 
passed through the cervix and about the neck were felt 
three loops of cord and beyond were many others. With 
the usual technique a version was readily done and as the 
baby was delivered a loop of cord was seen about its body 
and under each arm. The cord was not pulsating when the 
baby was born. The baby's heart was beating regularly but 
slowly. The cord was at once clamped and cut and the baby 
readily resuscitated. Fifteen minutes after the birth of the 
baby the placenta was delivered intact with all the mem- 
branes. The cord was measured and found to be fifty-eight 
inches long. The baby weighed five pounds and four ounces. 
The mother made an absolutely normal convalescence, tem- 
perature never rising above 99° or the pulse over 80. She 
nursed her baby and it did well. Both were well on the tenth 
day and were discharged. 



FACE PRESENTATION. 353 

Case 57. Face Presentation. Chin Anterior. In- 
ternal PoDALic Version. August 26th. Telephone from 
a physician at quarter past ten this evening saying that he 
now had a patient in labor who two years ago was delivered 
by a hard operative delivery, of a stillborn baby. That now 
there was a face presenting. That she was in active labor. 
He wanted me to see her at once with the question of perform- 
ing a Caesarean section. I went at once, to the hospital 
where she was, and obtained this further story from the phy- 
sician-in-charge. At the previous delivery he had started 
to operate with the head high and the cord prolapsed. He 
continued operating by forceps and lost the baby which is 
said to have weighed nine pounds. Mother had severe tears 
but made a good convalescence. Present pregnancy was not 
remarkable. She ruptured her membranes at six o'clock 
this afternoon and pains immediately started. The physi- 
cian -in- charge was out of town when the pains began. An- 
other physician saw her for him. This physician at that time 
examined her but could not make out what the presentation 
was. At eight o'clock her own physician examined her and 
found a face presenting. The chin was anterior, the cervix 
was partially taken up and the os uteri dilated about one 
inch. He brought her at once, without a sterile pad on, 
some six miles in the automobile, to the hospital. 

When I saw her she was in excellent condition. Pulse 80. 
Palpation showed definite small parts on the left. Back on 
the right. By the fourth manoeuvre fingers of the left hand 
went down in the pelvis very much further than did the fingers 
of the right hand which were held by the occiput. The 
uterus relaxed well between pains. The baby weighs about 
seven pounds. Vaginal examination at 1 1 .-30 showed the os 
very thin and dilated two and a half inches. A marked gain 
in a little over three hours from what the physician -in- charge 
had found. Irregularities of the face were evident. Chin 
was anterior and to the left of the median line making it an 
M. L. A. Promontory can just be reached. The contour of 
the pelvis is apparently normal. The spines of the ischia are 
very prominent. The arch is a little narrowed and with diffi- 
culty my closed fist can be pushed between the tuberosities. 



354 <^ASE HISTORIES IN OBSTETRICS. 

I was convinced that there was sufficient room in the pelvis 
for the baby to come through. I therefore tried to flex the 
head but was unsuccessful. 

The physician-in-charge, as was the patient, was anxious 
for a Csesarean section, but I advised against it for the follow- 
ing reasons: — First, she has had ruptured membranes for 
five hours; she had been examined by one doctor without 
sterile gloves and by two with gloves; she had been brought 
down at least six miles in an automobile without a sterile pad 
on with a very relaxed introitus. I felt that the present baby 
could be brought through without difficulty by an elective 
version when full dilatation was obtained, if she were unable 
to push the face as such into the pelvis. The patient still 
favored Caesarean section even after I talked with her but on 
talking with the husband I made it clear to him that the 
danger of sepsis if a Csesarean section were done was great and 
I again advised strongly against it. My advice was accepted 
and the patient continued in labor. At 12:30 a.m. palpation 
showed practically no difference in the height of the head. At 
this time the patient began of her own free will to bear down. 
At quarter- past one I again examined her and found she was 
fully dilated but the head had made no descent. I then 
advised operation and it was accepted. Preparations were 
immediately completed. Patient was scrubbed up carefully 
as already described. Under ether the patient was cathe- 
terized. Vaginal examination showed the os fully dilated. 
Position M. L. A. Marked edema of the face and brow 
present from palpation. 

In going up into the uterus with my right hand I came upon 
a definite retraction ring which, however, was not at all tight 
and needed no dilatation. The anterior leg was sought for 
and found and version begun. With excellent aid by my 
assistant, the version was readily performed. There was no 
difficulty until the perineal arm was sought. This was 
extended and only after several attempts was it swept down 
over the face and out. The anterior arm was only partially 
extended and it was delivered from its anterior position 
readily. There was but little difficulty with the after-coming 
head. The baby^s heart was beating regularly and well and 



FACE PRESENTATION. 355 

its color was excellent. The cord was not pulsating and 
therefore was clamped and cut. The baby was given to the 
assistant to resuscitate but before he put it into the hot water, 
it gave its first cry. Inspection of the perineum showed a 
slight internal tear on the left which was at once repaired 
with chromic catgut. The placenta was delivered intact 
with its membranes a short while later. There was no bleed- 
ing and the patient was at once put back to bed in excellent 
condition. The baby was carefully looked over, no bones 
were broken, and the arms were moved normally. 

Two weeks later the physician telephoned that both mother 
and child were at home and in excellent condition. 

Summary of Face Presentations. 

Anything which interferes with the flexion which is so 
essential to the normal mechanism of labor may cause a face 
presentation. In the first case recorded the loops of cord 
about the neck prevented flexion and my attempts here to 
flex the head on the chest interfered with the circulation in 
the cord as shown by the irregularity of the fetal heart. In 
the second case the position was originally an O. D. P. and 
in the course of the labor the biparietal bosses were probably 
held up by the slightly narrowed pelvis with the resulting 
extension. In the first the chin was posterior, in the second 
anterior. 

The treatment of all face cases, if they are seen early enough 
in labor, is to attempt to flex the head in order to convert 
the face into an occipital presentation. With the hand in 
the vagina, many times the change can be accomplished, but 
sometimes the moment the pressure is removed from the face 
or brow, extension again takes place. Simple flexion is not 
sufficient ; the poise of the child in the uterus must be changed 
and this is attempted by external manipulations. Illustrations 
in the various text books show these manipulations much 
better than they can be described. If the uterus is tightly 
contracted about the baby, external manipulations will be of 
no avail. 

If the chin is anterior and labor progresses well, the case 



356 CASE HISTORIES IN OBSTETRICS. 

may be left alone, but if progress is not made delivery must 
be undertaken. Here again the time to operate is when both 
mother and child are in good condition. If the chin is 
posterior and unengaged with the os uteri fully dilated, 
version should be done at once, provided flexion, as already 
spoken of, cannot be obtained. If a chin posterior position 
is found with the chin on the pelvic floor, many writers 
advise unhesitatingly to perforate the skull. That is scarcely 
justifiable at first. Attempt must be made to rotate the 
chin anteriorly manually or if this is unsuccessful, by forceps. 
This latter, however, is a dangerous procedure. If the 
patient is not in hard labor and the uterus is soft, one may 
attempt to push the head up out of the pelvis slowly and then 
perform a version. A few cases of persistent chin posterior 
positions have been successfully delivered by pubiotomy. 
If the child is dead, then, of course, a craniotomy should be 
done. 

In these two recorded cases version was the operation of 
election. In the first the danger of pinching the cord by the 
forceps was great. In the second the slightly flattened pelvis 
made a version the operation indicated. 

If the head can be flexed and held by an assistant so that 
forceps can be applied, a forceps delivery may be done. 
Under any circumstances careful watch must be kept on the 
progress of the labor to see that no untoward symptoms 
arise. 

If there is no disproportion between the pelvis and the 
baby and steady progress is made with the chin anterior, 
there is no indication to operate. A face presenting does not 
of necessity demand operative interference. But it must be 
remembered either complete extension or complete flexion 
of the head is essential for the mechanism of labor to be 
carried out. 



SECTION XV. 
TRANSVERSE PRESENTATION. 

Case 58. Transverse Presentation. Internal Podalic 
Version. My house officer telephones to me saying he had 
just seen a multipara in her fifth labor with a transverse 
presentation. She was in fair labor and the membranes had 
been ruptured eight hours. I arrived at the patient's house 
July 27th at 12:30 A.M. She was at once recognized as a 
patient I had seen previously many times in my Dispensary 
work. She greeted me with the remark that "you can't do 
anything until you give me ether and I won't get into that 
position for anyone." The explanation of this remark was 
that at the last delivery the house officer kept her on the edge 
of the kitchen table in Walcher's position for, she says, four 
hours, and that ever since she has had much pain in her back, 
all of which she lays to the position in which she was kept. 

Examination of the patient showed the uterus was con- 
tracting hard every three minutes and the pains were of one 
minute duration. The normal contour of a full term preg- 
nancy was absent. The transverse diameter of the uterus 
just above the pelvis was much increased and the epigastrium 
was fiat. The patient had a flabby pendulous abdominal 
wall. Through it the head was readily palpated on the 
patient's left, lying in the left iliac fossa. Smooth resistance 
was made out anteriorly with the buttocks on the right. 
Irregularities and fetal motion were felt at the fundus. The 
fetal heart was not heard. Uterus was soft between pains 
and not tender. Patient's pulse was 80 and she was in 
excellent condition. 

Vaginal Examination : — Previous severe perineal lacera- 
tions. Marked blueness of the vagina and prominent vulval 
varicosities with slight edema. The os uteri is fully dilatable 
and very thin. At the brim is a sharp bony prominence 
which is movable. Palpation of this prominence showed it 
undoubtedly to be the elbow, flexed and the forearm was 

357 



358 CASE HISTORIES IN OBSTETRICS. 

running towards the patient's left. At the right of the median 
line was found a large foot, heel at the right and toes pointing 
downward and to the left. Clear liquor was coming away. 
I advised the patient to be etherized and delivered. She 
readily assented. The preparations were completed and 
when everything was ready, including a pail of hot water to 
resuscitate the baby, she was etherized on the bed. The 
reason she was not put on a table was that there was no table 
in the house strong enough to hold her safely. The legs were 
held by two women friends. When the patient was under 
ether the vulva was thoroughly scrubbed up with soap and 
water and then washed off with corrosive sublimate 1-3000. 
She previously had been shaved. The perineum dilated up, 
on account of the severe previous lacerations, very readily 
and the cervix was then dilated carefully by the hand until 
the whole hand could readily be pushed through the cervical 
ring which was felt, up to now, to be intact. The closed fist, 
made as large as possible, was slowly brought through the 
cervix four times and the last time there was practically no 
resistance offered. The forearm and hand of the presenting 
right arm was now brought down and a fillet quickly put on 
this wrist. The end of the fillet was held up and out of the 
way by the house officer. The foot which was also present- 
ing was now seized with the right hand and the etherizer was 
told to draw up on the head which was at the left while 
traction downward was made on the leg. The head at once 
swung up into the fundus and as it went up the right arm with 
the fillet on it went up into the vagina. Traction on the right 
foot brought the right buttock down as the anterior. The 
bistrochanteric diameter of the baby engaged in the right 
oblique diameter of the pelvis. Traction downward on the 
leg brought the posterior buttock to the perineum and with the 
finger of the left hand in this posterior groin the buttocks were 
slowly delivered. The posterior leg, the left, was fully ex- 
tended. The body delivered slowly, and the extended leg was 
freed, remembering carefully its anatomy. The bisacromial 
diameter held in the right oblique diameter. Traction down- 
ward combined with lateral flexion brought the angles of the 
scapulae into view. Traction which up to now had been but 



TRANSVERSE PRESENTATION. 359 

slight on the fillet was increased and this arm and shoulder 
readily delivered. The body was now drawn to the operator's 
right and raised up. With the operator's left hand the 
posterior arm was sought. It was not extended and very 
readily was swept down over the chest wall and out. The 
body was now put across the right forearm with legs hanging 
on either side, the left hand placed over the baby's neck at 
the occiput and with traction downward combined with 
excellent suprapubic pressure the head was delivered on the 
second attempt. The baby gasped at once and very shortly 
cried. The cord was clamped and cut. There were no fresh 
tears of the perineum. There was no more than normal 
bleeding. The placenta was delivered intact with all the 
membranes, half an hour after the baby's birth. The house 
officer gave an intra-uterine douche of sterile water and 
followed it with a pint of 70% alcohol. 

The patient was in excellent condition as was the baby. 
The baby was found to weigh ten pounds. The patient made 
an absolutely normal convalescence, and got out of bed the 
ninth day. She refused a vaginal examination and was dis- 
charged from the hospital care on the twelfth day, both she 
and the baby well. 

Summary of Transverse Presentations. 

This case is an excellent example of a transverse presenta- 
tion. If transverse presentations are seen at the onset of 
labor an attempt may be made to rectify the presentation 
by external manipulation. If this is successful then the case 
is managed as any normal case, with one possible exception. 
If there is a tendency for the transverse presentations to recur 
then a firm abdominal binder, with pads on either side of the 
fetus, should be put on. King's method of pressure by the 
flexed thigh may be tried. In transverse presentations 
the labor may be slow, the membranes may rupture early and 
a small part or the cord may prolapse. Constant supervision 
when the fetus is lying transversely must be given by the phy- 
sician and preparations for immediate operation must be com- 
pleted early in the labor. If the pains are strong and frequent 



360 CASE HISTORIES IN OBSTETRICS. 

and no dilatation is accomplished, then a Voorhees bag should 
be inserted. As soon as it comes out then an internal podalic 
version is the operation of election. The danger in a trans- 
verse presentation to the mother lies in the fact that an 
operation, almost certain to be necessary, is put off too 
long, not infrequently until the uterus is tonically contracted 
about the child. The danger to the child is because deep 
asphyxia consequent upon a prolapsed cord or a hard opera- 
tive delivery so often occurs. Properly managed transverse 
presentations should show no maternal mortality. The fetal 
mortality depends largely upon the skill of the physician and 
the willingness he shows to operate early. In operating 
early I do not mean that the patient should be dilated up 
from nothing and at once delivered, for the shock consequent 
upon this procedure is great. If progress is made, then as 
soon as the os uteri is fully dilatable delivery should be under- 
taken. If the patient is a primipara with rigid soft parts and 
there are no contra-indications, a Csesarean section is justifi- 
able, especially so if there is a disproportion between the fetus 
and the pelvis. 

If an arm is prolapsed then a fillet, or sling as it is often 
called, should be placed about the wrist. To one who has 
never made use of a fillet on a prolapsed arm the great aid 
it gives in the delivery of the arm is most surprising. A fillet 
may be made out of any strong piece of cotton cut two inches 
wide and five feet long. It is folded into a slip noose and 
then passed over the hand and drawn tight. The reason 
for having it so long is that when doubled and slipped over 
the hand it must be long enough so that as the version is done 
and the arm goes up into the vagina the end of the fillet can 
readily be held outside of the vulva and away, so that it 
will not be in the operator's way. 

To sum up in a few words the management of a transverse 
presentation, — if progress in the dilatation of the os uteri 
be satisfactory, simply watch the fetal heart but be prepared 
to operate. If progress is unsatisfactory put in a Voorhees 
bag. Under all circumstances deliver the patient as soon as 
the OS uteri is fully dilated and do not wait and hope for a 
spontaneous version. 



SECTION XVI. 
SEPSIS. 

Case 59. Puerperal Sepsis. July 16. Patient rup- 
tured her membranes this morning at 11 o'clock and labor 
started at 7 p.m. this evening. During the night pains came 
at from three- to ten-minute' intervals, lasting fifteen to 
forty- five seconds. At six o'clock, July 17, vaginal exami- 
nation showed that the cervix was entirely taken up, and 
admitted one finger. She was at this time very fretful, not 
bearing her pains well. Her pulse had gone from 80 to 96. 
She was given J gr. of morphia subcutaneously. From 
now until after eight o'clock she was quiet but the pains 
continued of the same character. At half-past eight they 
changed and began coming rapidly every three minutes and 
lasting one minute. Rectal examination at half-past nine 
showed the head on the perineum. Os fully dilated. Fetal 
heart listened to but was not obtained although the nurse 
had obtained it half an hour before. Preparation for im- 
mediate delivery was made and a simple low forceps was 
done but the baby was born dead. Twenty minutes later 
the placenta was delivered intact and there was a question 
whether some of the membranes were not retained. There 
was no bleeding. Her pulse was 100 after delivery. Her 
blood pressure was 130. 

July 19. Temperature this afternoon 100.6° and pulse 100. 
Uterus at the level of the umbilicus and lochia scant. Ice 
bag put to the fundus and half a dram of ergot and half a 
dram of hydrastis given. Patient was raised up on pillows 
and was urged to roll over on her stomach to favor draining. 

July 20. Temperature 99.6°. Pulse 96. Uterus is two 
finger breadths below the umbilicus. Aside from the fact 
that the uterus still is large her condition is satisfactory. 

July 21. Temperature this morning 99.2°. Pulse 84. 

Uterus is slightly tender. Lochia is not free, no odor. Ice 

to the fundus is continued. 

361 



362 CASE HISTORIES IN OBSTETRICS. 

July 22. Temperature this morning 99.2°. Pulse 84. 
At one o'clock this afternoon she felt chilly all over. No 
real chill. Temperature 102°. Pulse 96. In view of the 
fact that the uterus was still large and the lochia was scanty 
it was determined to dilate the cervix, and there escaped a 
considerable amount of thick, brownish foul smelling lochia. 
The uterus was explored with a curette but nothing was 
obtained. Uterus then washed out with salt solution fol- 
lowed by 70 per cent alcohol. 

July 23. Temperature this morning 100.2°. Pulse 100. 
Fairly comfortable night. Some headache. Is aching all 
over. Does not feel like eating anything. She does not 
look sick. Uterus is still large. There is no abdominal 
distension. No tenderness anywhere. Temperature to-night 
is 101° and pulse 100. She is now outdoors night and day. 

July 24. She had a chill early this morning and tempera- 
ture at eight was 103°, pulse 140. Face is slightly flushed 
this afternoon. Abdomen is slightly distended. Uterus is 
three finger breadths above the symphysis. No abnormal 
sounds in the heart. Temperature to-night was 101.4°. 
Pulse no. 

July 25. Temperature this morning was 97° and pulse 
was 68. At 11.50 she had a chill which lasted for ten 
minutes and pulse went to 144 and temperature to 104°. 
Physical examination shows nothing different from the pre- 
vious note except that she looks very much sicker. Skin 
is dry and she is eating only fairly well but drinking well. 
Bowels are moving well. Temperature to-night 102.6°. 
Pulse 140. 

July 26. Previous notes were made by the physician who 
was in charge of the case while I was out of town. I saw her 
to-day at his request. Temperature this morning was 99.2° 
and pulse 90. She had a good night last night and felt very 
much better early this morning but at 9.25 she had a slight 
chill which lasted ten minutes. Half an hour later tempera- 
ture rose to 104°. Pulse 140. She reacted from this chill 
very much more quickly than she had from the previous ones 
and began perspiring within ten minutes and in a short time 
became comfortable. Physical examination to-day shows no 



SEPSIS. 363 

distension of the abdomen. No tenderness anywhere. The 
fundus cannot be felt. She is draining profusely and the 
pads are very foul. She was smiling and very bright and 
said that her appetite was very much better than it had 
been any day previously. Her temperature to-night was 
100.2° and her pulse was iio. She is still out of doors on the 
piazza all the time night and day. 

July 27. She slept well last night and has had no chill 
since yesterday morning. Temperature this morning 97.8° 
and pulse 84. She asked this morning for more food and 
seems much brighter and happier even than yesterday. 
This afternoon she had a chilly sensation but no real chill. 
Temperature taken half an hour after this chilly sensation 
and it was found to be 104° and pulse of 120. She had no 
headache after this chill and no profuse perspiration. 

July 28. Temperature this morning 99.2° and pulse 96. 
Had an excellent night and slept six and a half hours. High- 
est the temperature got to-day on four-hourly chart was 
102.2° and pulse 106. Even with this temperature she was 
very comfortable, was eating well and there are no untoward 
symptoms. 

July 30. Temperature has been normal all day. Pulse 
not over 90. General condition is rapidly improving. Lo- 
chia is still foul but less profuse. 

August 3. Steady improvement though the temperature 
rises at night in the neighborhood of 100°. Pulse steadily 
dropping and for the past two days has not been over 80. 

August 10. Patient has made a steady and rapid con- 
valescence. Now has absolutely no discharge from the va- 
gina. Absolutely no tenderness anywhere. She is to get 
out of bed to-morrow for the first time. 

August 14. Has been gradually moving around the piazza. 
No untoward symptoms have developed. Condition in 
every way satisfactory. 

August 16. She is to go home this afternoon from the 
hospital. Examination shows perineum well healed. Cer- 
vix has very slight bilateral tear. Uterus normal in position 
and size; freely movable. Nothing can be felt on either 
side. No tenderness whatsoever in the pelvis. 



364 CASE HISTORIES IN OBSTETRICS. 

Case 60. Uterine Sepsis. This patient is seen in consul- 
tation August 6th. The history as given by the physician- 
in-charge is as follows: — The patient, a primipara, had a 
normal pregnancy in all respects. Labor began at six o'clock 
the morning of August 4th and progressed normally. Shortly 
after midnight on August 5th the membranes ruptured and 
from then on she made good progress and delivered herself 
at half-past one of a six and a half pound baby. Placenta 
followed in half an hour and was intact with all the mem- 
branes. There was a slight median tear which the physician 
repaired with one silkworm-gut suture. When the physician 
left the patient two hours after the delivery she had a normal 
temperature and a pulse of 64. Late in the afternoon of 
August 5th the patient had a temperature of 101.6°, pulse of 
100. He found no explanation of this rise in pulse and tem- 
perature. At noon time to-day, August 6th, he found her 
temperature 103.4°, pulse 126, respirations 40. I saw her at 
five P.M. and she then had a temperature of 103°, pulse 120, 
respirations 36. Her face was flushed but she did not look 
sick. I was unable to obtain any history of illness just 
previous to her delivery. The physician said he had made 
but two vaginal examinations during the labor and that as 
far as he knew he had carried out the technique he always 
used with previous good results. He is confident that all the 
membranes and placenta came away. Physical examination : 
— Heart and lungs negative. Breasts are soft without lumps 
or tenderness. Abdomen slightly distended and tympanitic 
except over the uterus. No tenderness in either kidney 
region. Spleen not palpable. Uterus palpated one inch 
below the umbilicus. It is soft and distinctly tender. No 
deep tenderness on either side of the pelvis. Examination of 
the pad then on the patient showed very slight amount of 
discharge, red in color but very strong odor, almost foul. 
Further questioning brought out the fact that the patient 
since delivery had flowed very little. 

The diagnosis of retained lochia with sepsis was made and 
I advised that the cervix be dilated, that a teaspoonful of 
ergot be given every three hours for four doses ; that an ice- 



SEPSIS. 365 

bag be put to the fundus ; that the patient be propped up in 
bed and that her bowels be freely opened. 

The physician- in- charge later dilated gently the cervix 
under aseptic precautions with a Goodell dilator and reported 
that much foul smelling lochia at once came away. 

August 7. To-night the physician reports the afternoon 
temperature was 101°, pulse 100. Uterus is distinctly smaller, 
less tender and more firm. Lochia is profuse and foul smelling. 
Patient is eating well and slept well last night. 

August 10. Physician reports that two days ago the tem- 
perature was 100° in the afternoon but since then it has not 
been over 99.8°. Pulse has gradually dropped and to-day is 
80. The uterus is involuting well and the lochia is rapidly 
improving in odor but still is profuse and gradually becoming 
lighter in color. The further history of this patient was that 
she made an excellent convalescence, nursed her baby and 
gradually resumed her household duties. 

Summary of Treatment of Sepsis. 

It is impossible except in very many cases to give an ade- 
quate picture of puerperal sepsis. The two cases that I 
have given are typical. In Case 60 the onset was more 
rapid than usual for that type of sepsis. In Case 59 the 
onset was slow until the intrauterine manipulation took 
place, then the infection was rapidly spread. 

The two symptoms common to all forms of sepsis are an 
increase in the pulse rate and a rise in temperature. Any 
rise in temperature and pulse in a puerperal patient must 
be regarded at the outset as uterine sepsis in one of its vari- 
ous forms until by careful, intelligent physical examination 
it is proved that the cause is outside the genital tract. 

In not a few of the cases here recorded there has been a 
temperature during some part of the first three days. All 
of these cases have been regarded as septic until it was proved 
that the cause was not sepsis- In a few of them unques- 
tionably the temperature was due to the absorption from 
some of the tears that had taken place It is hardly fair 
to regard these cases as showing a puerperal sepsis for the 



366 CASE HISTORIES IN OBSTETRICS. 

temperature in nonel of the cases was but of fleeting char- 
acter. 

If physicians would take this stand and admit the presence 
of sepsis when it is present, a tremendous gain in the prac- 
tice of obstetrics would be made. Any physician may have 
sepsis occasionally. For these rare cases he is not to be 
blamed unless he has wilfully or carelessly broken the defi- 
nite surgical technique that must be carried out in every 
obstetric case. At the present time it is no credit for a 
physician to go through years of hard operative work and not 
obtain sepsis. It simply means that he has lived up to the 
best teaching of our times. But if a physician has every 
once in awhile a case of uterine sepsis he is to be severely 
condemned, for his technique unquestionably is wrong in 
some respects. 

As constant as is the rise in pulse and temperature, so 
are the other symptoms as variable. The presence or ab- 
sence of a chill is no absolute criterion of the severity of the 
infection. A chill the first twenty-four hours usually means 
a severe infection. Case 33 had two chills. The first un- 
doubtedly was due to the breast infection while the second 
was due to the septic perineum, yet the patient made an 
excellent convalescence as soon as the perineum was opened 
for drainage. Headache of varying severity is very common. 
Pain in the lower abdomen is most variable while tenderness 
on palpation over the uterus is present in the great majority 
of cases. Accompanying the tenderness over the uterus is 
found an alteration in the involution which normally should 
take place. The uterus where sepsis is present involutes 
more slowly and is usually distinctly softer than in a normal 
case. 

In both Cases 59 and 60 the alteration in the involution of 
the uterus was present together with a change from normal 
in the lochia. The amount, color and odor of the lochia must 
be carefully investigated and any alteration noted. If a 
physician does not know what normal lochia is, he will be 
entirely at sea when he meets a septic case. These are 
the usual signs and symptoms of sepsis. The earlier they 
appear post partum, usually the more severe is the infection. 



SEPSIS. 367 

The patient's general appearance must be considered in 
every case of sepsis. Experience with sepsis leads one to 
form a more accurate idea of its severity than any one sign 
or symptom. 

No word on the treatment of sepsis would be adequate 
unless its prevention was first insisted upon. I have al- 
ready gone over the care during pregnancy and the conduct 
of labor and the technique to be employed. The patient's 
resistance must be brought to the highest point of efficiency 
and in order to do this the physician must have careful over- 
sight of the patient the entire duration of pregnancy. Phy- 
sicians must regard an obstetric case as a surgical pro- 
cedure and all patients must be educated to realize that the 
safeguards that the best obstetricians throw about relatively 
few women are not without reason. If the technique, as 
already described for the delivery of the cases, is followed 
out in all respects, then sepsis will disappear. No one part 
of the technique can be omitted in any case. It is all es- 
sential to the patient 's welfare. 

In. the actual treatment of uterine sepsis there still is 
wide variation in what is advised. The pendulum at the 
present time unquestionably has swung far to conservatism; 
the results obtained are surely as good, if not better, than 
from the radical, the operative treatment. 

Conservatism in the treatment of puerperal sepsis is shown 
by Case 60, except in one respect and that is in the use of 
the dilator. To have carried out consistently the conserva- 
tive treatment the dilator should not have been used, but 
the picture was so complete of retained lochia with sepsis 
that I felt it best to give this retained lochia an opportunity 
to come away quickly, and the flow that came, following the 
dilatation, justified fully its use. An ice bag to the fundus of 
the uterus constantly, ergot in dram doses every four hours, 
free catharsis and a good diet and sleep sums up the conserv- 
ative treatment of uterine sepsis. Raising the shoulders 
helps materially in the drainage. Whether the patient is 
placed in the true Fowler's position or the body and shoul- 
ders simply raised on pillows makes but little difference. 

The radical treatment of sepsis consists in curetting the 



368 CASE HISTORIES IN OBSTETRICS. 

uterus and washing it out with either salt solution or sterile 
water. Many times after the uterine douche is given, a 
pint of 70 per cent alcohol is allowed to run in very slowly 
and what will is allowed to stay in the uterus and vagina. 
The douche should flow slowly and without force. The 
uterus is curetted either with a blunt curette or with the 
finger. It should be needless to add that any intrauterine 
treatment must be carried out with the most rigid aseptic 
technique. To give an intrauterine douche, good light is 
essential. The patient is best placed across the bed with 
legs flexed, her buttocks well on the edge of the bed. The 
vulva is washed off carefully with corrosive sublimate 1-2000 
and a bivalve speculum exposes the os uteri. This is then 
wiped off with 70 per cent alcohol. The curette is then 
passed directly into the uterus touching no part of the va- 
gina and the cavity lightly curetted. No attempt ever is 
made to curette to a solid base. The intrauterine douche 
nozzle is then passed after all air is expelled from the tube 
and nozzle. In giving a douche the physician must see that 
a sufficient return flow appears, otherwise some of the solu- 
tion may be forced up into the Fallopian tubes. If the 
finger is used to curette it is passed through the os uteri after 
the vagina has been wiped out with either 70 per cent alco- 
hol or corrosive sublimate 1-5000. I do not like the use of 
the finger in uterine sepsis because one must go through the 
vagina and in doing so unquestionably will carry germs up 
into the uterus and also the finger is not long enough to 
reach the fundus of the uterus in by far the majority of such 
cases. The objection to the curette is that the uterus is so 
soft that the danger of puncture is very real and also that it 
opens up new avenues of attack for the germs which al- 
ready are in the uterus. The latter to me is the more potent 
objection, for if a physician believes in curetting septic cases 
he must be able to do it without damage. 

Case 59 shows well the bad results that may be obtained 
from curetting a puerperal uterus that already is slightly 
septic. This patient had a large uterus with retained lo- 
chia and the cervix was dilated and much foul smelling 
lochia came away. Not satisfied with that, the uterus was 



SEPSIS. 369 

then curetted and in a short time the damage that was done 
was very evident by the chills, the irregular temperature 
and high pulse that at once followed. Careful study of the 
notes on this case shows the characteristic ups and downs of 
a septic patient. Had the physician in this case stopped 
with the dilatation of the cervix and not curetted the patient, 
I am confident, and he is also, that she would not have gone 
on with the severe sepsis that followed. 

In my own cases where I alone have examined the patient 
and am confident that the uterus is properly emptied I have 
never yet given any intrauterine treatment. This statement 
is of no credit to any physician, for if the proper technique 
is carried out all physicians should have the same result. 
It is permissible, if the diagnosis of sepsis is doubtful, to give 
one intrauterine douche at the onset, but to continue the use 
of douches when the diagnosis is uncertain and no improve- 
ment in the patient's condition follows is entirely unwarranted. 

Bacteriological examination of the interior of the uterus, of 
uncontaminated lochia, is for the average physician out of the 
question. From a scientific point of view it is interesting 
but I do not believe the treatment is altered one iota by the 
findings from such examinations. Too many times have I 
found streptococci in lochia without symptoms in the patient. 
Clinical symptoms are of much more value than bacterio- 
logical findings. The use of vaccines either of the stock 
varieties or autogenous ones has, in the many cases I have 
seen, been unsatisfactory. It is true many brilliant results 
are recorded, but I have seen as many interesting recoveries 
take place from both the radical and the conservative methods 
of treating sepsis. 

Case 60 shows clearly the conservative treatment. Before 
any treatment is begun a careful, complete physical examina- 
tion must be made to be certain that there is no other cause 
for the rise of the temperature and pulse. If no sufficient 
cause is found outside the uterus then the uterus and its 
contiguous organs must be suspected as the cause. If, 
however, there are no localizing symptoms which point in the 
slightest degree to the uterus, then one must wait for further 
developments. Without localizing symptoms I do not be- 



370 CASE HISTORIES IN OBSTETRICS. 

lieve it best to start intrauterine treatment under all cir- 
cumstances. Conservative treatment may be begun at once 
on the chances that the rise in temperature is due to uterine 
sepsis, to be given up if necessary, when more definite symp- 
toms in other organs arise. 

The conservative treatment, as I have already said, con- 
sists in placing an ice bag over the fundus of the uterus, in the 
giving of an active preparation of ergot in dram doses every 
four hours, in the raising of the patient 's shoulders to favor 
drainage and in opening freely the patient 's bowels. 

Radical treatment means intrauterine manipulations 
added to the conservative treatment. In all cases of sepsis 
the patient should be on a four-hourly pulse and temperature 
chart. Careful palpation of the abdomen must be carried out 
daily with vaginal examinations now and then in order to 
rule out the accumulation of any pus in the pelvis. A normal 
temperature and a dropping pulse for five days rules out al- 
most certainly the presence of uterine sepsis. With a tem- 
perature hovering about 100° and a pulse that does not have 
the normal drop in rate after delivery, the probability of 
uterine sepsis must be kept in mind. 

Food and fresh air must be given freely to a patient suffer- 
ing from sepsis. The more severe is the sepsis the more 
essential is it that the patient be put out of doors. To 
those physicians who have never seen the results of out-of- 
doors treatment of sepsis, they are truly astonishing and 
well repay the effort that such treatment sometimes neces- 
sitates. 

As much food of varied kinds as the patient can digest must 
be urged. High temperature is no contra-indication for a 
full diet provided the patient can digest the food that is 
given her. 

If the patient is running a very high temperature, cold 
sponge baths give the greatest relief. The coal tar deriva- 
tives must not be used. Stimulation of the heart may be at 
any time indicated and in order that the heart condition is not 
overlooked careful frequent examinations must be made. 

If there is much pain present with the sepsis, small doses 
of codeia may be used to obtain sleep. If there is no pain. 



SEPSIS. 371 

one of the simple hypnotics should be used to give the patient 
a good night 's sleep. 

The use of alcohol in sepsis is a much debated question. 1 
do not use it if the patient can get a sufficient amount of 
nourishment without it. But if she is unable to eat well I 
do give it as a food, not as a stimulant. Give up its use as 
soon as possible for by its use more than one patient has been 
made a slave to it. 

The question of nursing the baby will come up many times. 
In severe sepsis the milk usually disappears and the answer 
is self-evident. In long drawn-out cases of sepsis the baby 
should be taken off the breast, but if by clinical signs the 
patient at once begins to overcome the sepsis then the nurs- 
ing should be continued 

Important as the medical treatment is, the nursing care 
in sepsis is more so and without careful nurses efficient work 
cannot be carried out. 

That sepsis is the cause yearly of many deaths is a re- 
proach to the medical profession. Until the standard of 
obstetric teaching is raised, until the laity at large become 
educated to the point that they will demand good obstetric 
care, then only will the death rate from puerperal sepsis be 
materially lowered. The mid wives are bad offenders but 
their mortality and morbidity rates do not I believe approach 
the high morbidity rate of the poorly trained physician. 
The physician is licensed in all states, but the midwife in 
most states is simply tolerated. The physician goes ahead 
recklessly because he is licensed; the midwife has some fear 
of the law, and so her results usually are not so bad as those of 
the licensed physician who is poorly educated and trained, 
who has no fear of the law and is without conscience. 



SECTION XVII. 
PHLEBITIS. 

Case 6i. Double Phlebitis. This patient started in 
labor December 19th at ten p.m. It is her second labor, the 
first terminating in a normal delivery. She has always been 
a very strong and healthy woman. Pains did not become 
severe until six a.m. December 20th. At twenty minutes 
past six the membranes ruptured and she began to bear down 
at once in excellent second stage labor. At five minutes past 
seven the baby was born. There was no tear of the perineum. 
At quarter-past seven the placenta came away intact with 
all the membranes. There was no bleeding and she was in 
excellent condition. One vaginal examination was made in 
the middle of the first stage of labor under the usual aseptic 
precautions with sterile gloves. 

The patient made an absolutely normal convalescence until 
the seventh day, when she complained of sharp pain in the 
lower abdomen and in the left groin. Absolutely no tender- 
ness any^vhere on palpation. Temperature normal. Pulse 
78. An ice-bag ordered to the left lower abdomen. 

December 28. Temperature to-night 100.2°, pulse 84. 
There is very slight tenderness in the left groin. Ice-bag 
continued and the patient told to keep very quiet in bed. 
Bowels are moved daily by enema. 

December 30. Temperature this morning 99.5°, pulse 92. 
There is still very slight tenderness in the left groin but no 
swelling of the calf of the leg. 

January i. No tenderness in the groin yesterday. The 
ice-bag was omitted. This morning temperature normal, 
pulse 100. She complains to-day of pain in the calf of the left 
leg. Examination showed it to be slightly swollen and more 
tense than the right leg. It was found to be half an inch 
larger than the right. The leg was at once put up in a pillow 
splint. The patient was warned that she must be absolutely 
quiet and not attempt to move this leg. 

373 



374 CASE HISTORIES IN OBSTETRICS. 

January 2. The skin is shiny and there is edema pres- 
ent at the ankle. Landmarks of the knee joint are in- 
distinct. Tenderness in the groin has entirely gone. Ice is 
kept constantly on the calf of the leg. Temperature to-night 
100.8°. Pulse 104. 

January 4. Pulse has dropped to 72 but the temperature 
remains slightly elevated from 99.6° to 100°. The skin over 
the calf is not as tense as last note and the tenderness is 
distinctly less. 

January 6. Temperature last night 101.4°, pulse 108. 
She complained of slight shooting pains throughout the right 
leg. There is this morning very slight tenderness at the 
pelvic brim on the right. No tenderness in the groin or calf 
of the right leg. There is no tenderness or swelling in the left 
leg. Temperature this morning is normal but the pulse is 104. 
Ice-bag ordered to the right lower abdomen. 

January 8. Tenderness to palpation along the course of 
the internal saphenous vein of the right leg is present. There 
is very slight swelling of the leg, slight tenderness in the right 
groin. The leg was encased in a pillow splint and the icebag 
put on the right groin. There is no tenderness of the left leg 
and the pillow splint is removed. Temperature to-night is 
102.8° and pulse 108. 

January 10. This morning she complained of much pain on 
the outer side of the right ankle. Pillow splint was taken 
down and examination shows over the external malleolus a 
red area the size of a silver dollar which is exquisitely tender 
to the touch. No fluctuation present. The ankle joint is 
not involved. Pillow splint was left open and the foot sup- 
ported by another pillow so that there will be no toe drop. 
All pressure to be kept off the external malleolus. Because 
of the pain in the leg to-night she was given morphia 
gr. 1/8. 

January 14. Redness and tenderness has entirely gone 
from over the external malleolus. Practically no swelling 
in the leg and very little tenderness. Patient has constantly 
been warned not to move her legs. 

January 16. Temperature to-night is normal for the first 
time for three weeks. Pulse is slowly coming down to normal. 



PHLEBITIS. 375 

January 23. Sat up in bed with a bed rest to-day. No 
rise in temperature or pulse. 

January 29. Sat up in a chair yesterday with her feet 
elevated. To-day she was allowed to sit up in a chair for two 
hours with her feet on the floor with no bad results. 

January 31. She is now walking about the ward and has 
but very little swelling of the feet and none of the calves of 
the legs. The baby throughout the entire time has nursed 
and was satisfied and gained slowly but steadily. 

Summary of Phlebitis. 

Phlebitis in all cases is a form of sepsis. Infection is 
present and the physician must not try to hide behind any 
excuse. Be as careful as one can, and phlebitis will rarely 
follow. When all possible precautions against sepsis have 
been taken and a phlebitis follows, no blame can be placed 
upon the physician. If the physician is careless in his 
technique and infection follows, then he is to be blamed. If 
in his practice he obtains many cases of phlebitis it is proof 
that there are errors present in his technique of delivery. 

Phlebitis usually appears about the tenth day but not 
uncommonly it is seen by the sixth or seventh day, rarely after 
two weeks. The first sign that appears is a slow rise in the 
pulse rate and then the temperature climbs by step-ladder 
rises. A high temperature does not always accompany a 
phlebitis. A high temperature and pulse rate is indicative 
of the severity of the condition. 

Coincident with the rise in temperature or coming within 
a few hours of it, the patient complains of pain in the affected 
leg or on one or the other sides of the lower abdomen as did 
Case 61. Tenderness to palpation along the course of the 
affected vein follows closely upon the pain. If you palpate 
the leg do it very gently and only often enough to follow the 
progress of the complication. Edema of the leg is present 
and the slower the collateral circulation is established the 
greater is this edema. 

The first point to be insisted upon in the treatment is 
absolute rest of the leg. The patient must under no circum- 



376 CASE HISTORIES IN OBSTETRICS. 

stances move the leg. I believe in telling the patient in a few 
simple words what the condition is and warning her that rest 
is the essential point for her to keep in mind constantly. A 
pillow splint holds the leg well and is very comfortable. 
Care must be taken to avoid too much pressure on the leg. 
The importance of this is seen in the above case. If the 
patient complains of pain the leg must be carefully examined 
and it is not to be assumed that the pain is caused by the 
phlebitis alone. Sandbags beside the leg are satisfactory 
but they must be kept close to the leg constantly if they 
are to be of service. In all cases hold the foot up at right 
angles to the leg by placing a firm pillow at the plantar aspect 
of the foot. This prevents toe drop and the comfort given 
the patient is great. 

An ice-bag to the point of greatest pain and tenderness gives 
the patient much relief but in a few patients the ice-bag is very 
annoying and then heat in the form of a flaxseed poultice is 
acceptable. If the pain is severe, codeine sulphate or morphia 
must be used, for if the patient is made comfortable then her 
ability to lie quietly in bed is much increased. 

The patient's bowels should move once a day and she must 
be put on the bed pan by the nurse, for all voluntary motions 
of the legs on the patient's part are forbidden. Whether the 
patient is allowed to continue nursing depends entirely upon 
the severity of the phlebitis and upon her general condition. 
Each case must be settled upon its own merits. 

The majority of physicians appreciate the danger when a 
phlebitis is present of embolism while the patient's pulse and 
temperature are elevated, they are apt to forget that the 
danger is present for some days after the pulse and tempera- 
ture have become normal. After the mildest cases of phle- 
bitis the patient should be kept in bed at least one full week 
after the pulse and temperature are normal. In severe cases 
two weeks should pass before the patient can be allowed out 
of bed. The patient must get up slowly and gradually, first 
a bed rest, then a chair with her feet elevated, then a few 
steps. One cannot be too slow in allowing patients in such 
cases to resume their daily routine. If the leg swells then it 
must be bandaged from the toes to the groin with Shaker 



PHLEBITIS. 377 

flannel cut on the bias. More expensive is the elastic band- 
age or a silk elastic stocking. If the latter is used, it must be 
carefully fitted. Whatever form of bandage is used it must 
be put on before the patient gets out of bed. If the leg is very- 
stiff and walking is difficult after two months, massage of the 
leg may be begun, for by that time there is no danger that any 
manipulation will cause an embolus. 

Rarely does the infection in a phlebitis, which is a peri- 
phlebitis as well, break down, and go on to abscess forma- 
tion. Careful daily examination of the leg will show if this 
occurs. If abscess formation does occur the pus must be 
evacuated under a well -recognized surgical procedure. 

Because a patient has once had a phlebitis is no proof that 
she will in another confinement develop a second phlebitis. 
Be honest with your patients, if a phlebitis develops it is not 
caused by their doing this or that or by their neglecting to 
do this or that thing. The complication is an infection; 
the physician is not necessarily to be blamed unless he is 
careless. No excuses for this trying complication are neces- 
sary and if any are given the physician generally realizes that 
his technique is at fault and is trying to cover up his care- 
lessness. 



SECTION XVIII. 

PYELITIS IN PREGNANCY AND IN THE PUER- 

PERIUM. 

Case 62. Pyelitis in Pregnancy. Patient presents her- 
self at the office November 8th, five months advanced in her 
second pregnancy. Her first baby was born eighteen months 
ago and was terminated by instruments after a forty-eight 
hour labor. She says she was badly torn but that the tear 
was repaired at once. She says she made a fair convalescence. 
She was at this time catheterized three times a day for several 
days. She says that now she has no pain on urinating, no 
increased frequency, more than what she would expect to 
have because of her pregnancy. She says that her urine has 
been examined twice recently by a general practitioner and 
that each time nothing has been found wrong with it but she 
brings a specimen with her which she says was passed one- 
half hour before she came to the office and that it has the same 
characteristics as the urine that had been previously examined. 
She wants to know if it really is right because it has such a bad 
odor. The odor was present when it was passed. Except 
for the fact that she is passing a bad smelling urine she thinks 
she is in very good condition. Bowels are moving without 
medicine. She is sleeping well and her appetite is excellent. 
Specimen that she left was normal in color, alkaline reaction, 
very cloudy, specific gravity 1.014. Albumin very slight 
trace, sugar absent. It does not filter clear. Microscopic 
examination of gravity sediment shows much pus, many 
leucocytes, singly and in clumps, many bladder cells, few 
large round cells, many smaller and less dense cells than the 
bladder cells, much vaginal epithelium. No casts seen. 

Patient was immediately put on hexamethylenamine gr. v, 
every four hours in one-half a glass of water. 

November 16. Patient reports to-day that she is passing 
three pints of urine, and that the odor is not quite as 

379 



380 CASE HISTORIES IN OBSTETRICS. 

bad as before. Specimen passed in the office was normal in 
color, acid, not as cloudy as the first, specific gravity 1.016, 
albumin slightest possible trace, sugar absent. Sediment 
shows pus present but not in such amounts as in the first spec- 
imen. Otherwise specimen is the same. Sediment was 
centrifugalized and a slide stained with methylene blue. Ex- 
amination shows enormous quantities of a large thick bacillus, 
probably the colon bacillus. 

November 22. Patient telephones this noon that she is 
having an attack of pain on the right side of the abdomen and 
also in the back. The pain runs down her right leg. She 
is seen at once, and the following history obtained. While 
walking about her home, she was seized with a sudden sharp 
pain on the right side of the abdomen low down. It is 
constant. Severe enough to make her go to bed. She has 
no increased frequency in passing her urine. She has not 
had any chill. She has had no nausea or vomiting. Bowels 
moved well this morning. Examination of the abdomen 
shows a pregnancy advanced about five months. Fetal 
motion is very marked. Uterus is soft, no contractions are 
seen or felt. Along the right border of the uterine tumor 
posteriorly she complains of tenderness on palpation. There 
is no spasm. The rest of the abdominal examination is 
negative. There is distinct tenderness and slight spasm in 
the right cos to- vertebral angle on pressure. Motion in the 
right hip is normal and there is no tenderness anywhere in 
the right leg. Temperature is 100.6°. Pulse 100. Diag- 
nosis: Pyelitis. 

Treatment: She is told to stay in bed. To have a simple 
bland diet. To force the fluids and to put an ice-bag over 
the right kidney region. To take 20 drops of cascara at once 
and in the morning to take a suds enema. To measure and 
keep the twenty-four hour amount of urine. To continue 
the hexamethylenamine as before. 

November 23. Patient slept well last night. Tem- 
perature is normal. Pulse is 80. Tenderness is distinctly 
less along the right side of the uterus and very much less over 
the kidney and there is no spasm. Twenty-four hour amount 
of urine is two quarts, pale, acid, specific gravity 1.006. 



PYELITIS IN PREGNANCY AND IN THE PUERPERIUM. 38 1 

Urine is but slightly cloudy. Albumin slightest possible 
trace. Sediment same as last noted but much less in amount. 
Her baby is ill and she got up this afternoon. Apparently 
it did her no harm for the evening temperature was normal 
and the pulse was 80. 

November 24. The patient now has no pain or tender- 
ness anywhere and she is up and about the house. Urine 
has been acid for the past three days, the patient testing it 
daily by litmus paper. It was now changed to alkaline by 
the use of potassium citrate gr. xl every two hours. Bowels 
were kept open. 

November 25. Specimen sent to the office, not of a 
twenty-four hour amount, is very cloudy, much sediment 
macroscopically. Microscopically same elements as before 
except that in this specimen there were many more bladder 
cells. Because of the amount of pus that is still present and 
because of the number of bladder cells in the urine I advised 
that the bladder be washed out. 

November 26. Comes to the office. Bladder washed 
out with 4% boric acid solution and one ounce of 10% solu- 
tion of protargol allowed to remain in the bladder. She has 
no pain now on the right side and apparently is very com- 
fortable. Temperature is 98.6°, pulse 80. 

November 29. Examination of the urine shows great 
improvement. But slightly cloudy. Slight amount of sedi- 
ment. Specific gravity i.oio, alkaline. Twenty-four hour 
amount, two quarts. Albumin slightest possible trace. Pus 
cells show a few clumps, but the majority are single. A very 
few fine granular casts seen. 

From now on for the next month the patient changed her 
urine over every third day from alkaline to acid, and vice 
versa by the use of potassium citrate and sodium benzoate 
with marked improvement. The bladder was washed out 
regularly three times a week as above noted for two weeks. 

December 24. Urine filters absolutely clear. There is 
no bad odor present, acid, pale, 1.005, albumin and sugar 
absent. Microscopically, few leucocytes, singly and in 
clumps, no clumps of bladder cells. No blood and no casts. 
Stained specimen of the sediment shows very few bacteria. 



382 CASE HISTORIES IN OBSTETRICS. 

The urine was examined from now on every ten days and 
there was a steady improvement. Once a week the reaction 
of the urine was changed from acid to alkaHne and held 
alkaHne for forty-eight hours and then again made acid. 

February 12. Urine: specific gravity i.oio, color 
normal, acid, no albumin or sugar. Sediment very slight 
and settles rapidly, leaving the urine absolutely clear. Micro- 
scopic examination of the sediment: occasional bladder cell, 
few leucocytes. No clumps seen. Few large round cells. 
Stained specimen of the sediment shows bacteria in about the 
same manner as previously noted. The patient is in excellent 
condition and the pregnancy is progressing satisfactorily. 

March 30. Slight uterine contractions with pain started 
up at half-past eight this morning. By five p.m. she was in 
active labor and about seven she was fully dilated and at 
ten minutes to eight she delivered herself. No fresh tear of 
the perineum. She made an absolutely good convalescence, 
except for very severe after-pains for which she had to have 
morphia. The first attempt at voiding her urine was unsuc- 
cessful. She was then given a high, large, hot enema and 
when she expelled this she voided her urine. 

April 24. The urine was collected after the vulva was 
carefully washed off and urine passed into a clean dish and 
then put into a clean bottle. Urine normal in color, clear, 
acid, 1. 012. On standing shows very slight sediment. No 
albumin, sugar not done. Sediment centrifugalized and it 
shows a rare blood corpuscle, very occasional leucocyte, rare 
dense, large round cell, probably bladder cell. Few calcium 
oxalate crystals. 

June 13. Specimen passed into a sterile basin. Normal, 
clear, acid, 1.002. No albumin. Entire specimen centrif- 
ugalized and microscopic examination showed a few squa- 
mous epithelial cells. No casts, no blood, rare leucocyte. No 
bladder cells seen. The patient is in excellent condition, the 
baby is doing well on the breast. Pelvic examination is 
satisfactory and the patient is discharged well. She was told 
that she should not become pregnant again for at least two 
years and then not until her urine had been examined and 
pronounced normal. 



PYELITIS IN PREGNANCY AND IN THE PUERPERIUM. 383 

Case 63. Pyelitis in the Puerperium, November 2. 
Patient has had a normal pregnancy. At no time has the 
urine shown anything abnormal. Blood pressure has not 
been over 120 mm. at any time during the pregnancy. She 
started in labor on November 2nd. The membranes rup- 
tured coincident with the first pain at 11 p.m. She im- 
mediately went into a private hospital. During the night 
she had pains every ten or fifteen minutes until eight 
o'clock on the morning of the third. Pains then began coming 
once in four minutes. There was no show. At nine o'clock 
she began having considerable amount of show. Vaginal 
examination at this time showed the head well in the pelvis; 
she was dilated about two- thirds and the anterior lip of 
the cervix was slightly edematous. Attempt was made to 
push back the anterior lip of the cervix but it was not suc- 
cessful. Fetal heart was 120 in the left lower quadrant. 
At half-Dast nine she was given gas-oxygen with marked 
relief. From nine to eleven there was no difference in the 
character of the pains. Shortly after eleven, on listening to 
the fetal heart it was found to have dropped to 90, and I 
determined then to deliver her. She was at once etherized. 
Vaginal examination showed she had made very little progress 
since the previous examination. She had a very tight per- 
ineum which tore on her right during the stretching. For- 
ceps were rapidly applied to an O.L.A. position and the 
head brought in sight. Circulation was then seen to be 
present in the scalp and from then on a slow delivery followed. 
Baby cried as soon as it was delivered and was in good con- 
dition. Perineum showed an internal tear on her right 
running up on the right vaginal wall, which was repaired with 
four chromic catgut sutures bringing the perineum into ex- 
cellent approximation. Very slight external tear repaired 
with two chromic catgut sutures. The baby weighed seven 
pounds. 

November 3. Temperature 98.6° and pulse 90. In ex- 
cellent condition. Uterus well contracted. Lochia normal. 
She complains of nothing except pain on the right side running 
from the right border of the ribs back towards the costo- 
vertebral angle. Palpation shows no tenderness and no spasm. 



384 CASE HISTORIES IN OBSTETRICS. 

November 4. Temperature 99° and pulse 80. In ex- 
cellent condition. No tenderness anywhere. She does not 
at the present time complain of pain on the right side. Tem- 
perature to-night 101°. Pulse no. Physical examination 
shows absolutely nothing. No tenderness in the perineum or 
at the costo-vertebral angle. Breasts are becoming slightly 
full but do not account for the temperature. 

November 5. Temperature this morning dropped to nor- 
mal. Pulse 68. Complained this morning of slight burning 
on urinating. 

November 6. Temperature this morning 99° and pulse 90. 
Careful physical examination showed nothing that I can 
find to account for the rise in pulse. Temperature to-night 
101° and pulse 100. She again complained of burning on 
voiding and I asked the nurse to get a specimen uncontami- 
nated with lochia as soon as she could. 

November 8. Temperature this morning 99°, pulse 90. 
She has had no more burning on micturition. She has had 
absolutely no sign on physical examination and she feels per- 
fectly well. Said last night she had slight headache. Other- 
wise nothing to note. Specimen obtained this morning, after 
the introitus was wiped off with sterile water and a sterile 
basin put at the introitus, was very cloudy and on standing 
in the urine glass a sediment of about one inch was deposited. 
Examination of this urine shows it to be pale, acid, specific 
gravity 1.012, slightest possible trace of albumin, no sugar. 
Sediment, quantities of pus, singly and in clumps; many 
large round cells and fewer smaller round cells; no vaginal 
epithelium present and no blood. 

Diagnosis : Pyelitis. 

The tenderness she had on the right side five days ago was 
in all probability due to this condition. 

Treatment : She was put on forced fluids, absolutely simple 
diet and given 5 grains hexamethylenamine every four hours. 
Temperature to-night 100°. Pulse is 108, the highest it has 
been since delivery and a steady rise in the past four 
days. 

November 10. Temperature yesterday not over 99.2°. 
Pulse under 100. To-day it has not been over 99^ and the 



PYELITIS IN PREGNANCY AND IN THE PUERPERIUM. 385 

pulse has been 92-96 all day. She Is passing large quan- 
tities of water which is very pale and acid in reaction. 
Sediment shows fewer leucocytes than on the first exam- 
ination. 

November 12. Temperature this morning struck normal. 
Pulse 90. She is in excellent condition. She is passing large 
quantities of pale urine. Each specimen has been looked at 
macroscopically and is clearer but still cloudy. 

November 14. Temperature to-night normal. Pulse has 
dropped to 72. Since last note there has been no change in 
the characteristics of the urine. I therefore put her on to 
potassium acetate 30 grains every two hours for three doses 
and asked to have the urine tested after four hours each time 
she voided. Hexamethylenamine stopped. Urine at the end 
of the third dose of potassium acetate was alkaline and it 
was then diminished to 15 grains every four hours with the 
order that the urine should be kept alkaline and if that dose 
did not keep it alkaline to increase the dose so that it would 
remain alkaline. 

November 17. Temperature has been normal and the pulse 
below 90. Lochia has practically ceased and she is up on, a 
bed rest. Has absolutely no tenderness over either kidney. 
No tenderness anywhere. Urine has cleared very much so 
that now it can be readily seen through. The sediment is 
the same though very much smaller amount of pus is present 
and very few clumps of pus seen. 

November 21. Has been up and about the hospital for 
the past three days. In excellent condition. Urine is still 
alkaline. Is clear. Each specimen is looked at and none 
has been found to be cloudy. Urine passed this morning 
pale, alkaline, specific gravity 1.002, with no albumin. Sedi- 
ment very slight and only an occasional leucocyte seen. 
Potassium acetate stopped to-day. 

November 2"]. Went home five days ago. Has been run- 
ning absolutely normal temperature and a pulse between 
70 and 80. Urine remains perfectly clear. Single specimen 
examined to-day shows it to be acid in reaction, specific 
gravity i.oio. No albumin or sugar. Centrifugalized sedi- 
ment shows very occasional leucocyte and a few round cells. 



386 CASE HISTORIES IN OBSTETRICS. 

Summary of Pyelitis in Pregnancy and in the Puerperium. 

Pyelitis in pregnancy and in the puerperium up to within the 
past few years has been regarded as an unusual complication. 
It is, however, not at all an uncommon occurrence. It is a 
very simple diagnosis to make provided the physician will 
take the trouble to make a careful complete physical examina- 
tion. 

Pyelitis is overlooked only when there is no blocking up of 
the ureter of the kidney effected. If drainage is good then no 
constitutional symptoms arise, but pus is found in the urine. 
The more complete the blocking of the ureter the more severe 
the constitutional symptoms. If the ureter is blocked pus 
is not necessarily found in the urine, but tenderness over 
the costo-vertebral angle of the side affected is always found. 
This tenderness, oftentimes with spasm, is so constant that 
it may almost be called pathognomonic of pyelitis. 

In Case 62 the diagnosis might readily have been confused 
with acute appendicitis because here the pain was right 
sided as it most often is. Careful palpation, the finding of 
costo-vertebral tenderness and examination of the urine micro- 
scopically in all pregnant cases when there is acute abdominal 
pain will clear the diagnosis. 

In Case 63 the cause of the temperature that the patient 
was running was not clear. Only once was there any tender- 
ness over the kidney and then it was very slight. The diffi- 
culty of diagnosis here came in the fact that she had a perineal 
tear, and it was only by careful palpation of the perineum and 
watching the lochia, together with the microscopic examina- 
tion of the urine, that the diagnosis was clear. If an uncon- 
taminated specimen of urine cannot be obtained, a catheter 
specimen must be obtained in order to clear the diagnosis. 

Change in micturition from normal, either of frequency or 
of pain, is most common, but absence of any change is not 
sufficient reason for not making a diagnosis of pyelitis. 

The cause of most of the cases of pyehtis is the colon 
bacillus. How it gets into the kidney is a mooted question as 
is also the reason for the right kidney being affected more 
often than the left. 



PYELITIS IN PREGNANCY AND IN THE PUERPERIUM. 387 

The treatment first to be begun is a bland diet, forced 
fluids and free catharsis, with the giving of a urinary anti- 
septic. If improvement does not follow, more active treat- 
ment must be instituted. Ureteral catheterization and lavage 
of the pelvis of the kidney has been recommended, but the 
further along the patient is in her pregnancy the more diffi- 
cult this is to do. Vaccines have been used with success by 
some physicians but with the majority these two methods 
of treatment are not available. Alternating the reaction of 
the urine from acid to alkaline has clinically given me many 
excellent results. This is accomplished by first giving sodium 
benzoate gr. v every hour until the urine is markedly acid 
as shown by litmus paper. The reaction is then changed 
quickly to alkaline by potassium acetate or citrate in large 
doses, thirty or forty grains every two hours. Several writers 
have reported excellent results from the use of potassium 
acetate alone. 

Only rarely will pregnancy have to be interfered with 
because of a pyelitis, but if it fails to yield to treatment and 
constitutional symptoms are present, then the uterus must be 
emptied. The prognosis for ultimate complete cure in pye- 
litis must always be guarded. A patient once infected, if she 
becomes pregnant again, very likely will have exacerbations 
during the pregnancy; how severe they will be is always 
doubtful. With careful supervision patients may go through 
a pregnancy with no upset but it cannot be guaranteed. 

A patient who has once had a pyelitis should not go through 
another pregnancy until the urine by careful microscopical 
and bacteriological examination is shown to be normal. This 
must be insisted upon, but if the patient, after being warned 
not to, becomes pregnant again, the presence of a pyelitis is 
not sufficient cause for emptying the uterus. 

Pyelitis in pregnancy may be a very serious complication 
and is one that always demands most careful oversight during 
the entire pregnancy. If after pregnancy the condition does 
not clear up, the question of the presence of a surgical kidney 
must be considered and, if present, ultimate cure will not 
follow until the kidney is drained by incision or removed. 



SECTION XIX. 
MASTITIS AND BREAST ABSCESS. 

Case 64. Acute Mastitis. This patient was delivered 
twenty-one days ago. In the afternoon of the twenty-first 
day of her convalescence she complained of a severe head- 
ache; otherwise she was feeling perfectly well. Temperature 
at 4 P.M. had been recorded as 99°, pulse 76. At eight o'clock 
in the evening she had a chill which lasted for twenty minutes. 
Temperature a half an hour after the chill was over, was 102° 
and the pulse 120. Except for a severe headache and some 
indefinite sensations of pain in the right breast there are no 
subjective symptoms. The baby has been nursing regularly 
and well from the breasts, and the nipples have not been 
tender. 

I saw the patient at ten o'clock in the evening. She then 
was complaining of slight tenderness to pressure in her right 
breast. She had a severe throbbing headache. Tempera- 
ture at this time was 103°, pulse 126. Complete physical 
examination was absolutely negative except for the tender- 
ness throughout the entire right breast on palpation. There 
is no lump present. Breast is not full. There is no crack in 
the nipple. 

Diagnosis : Acute mastitis. 

Treatment : Baby to be taken off the breast. Ice-bag is to 
be put constantly to the breast. Breast to be supported by 
a light breast binder. The patient was given a teaspoonful 
of cascara to be followed in the morning by an enema. 

Morning of the twenty-second day temperature 98.6°, pulse 
dropped to 85. Definite lump, the size of a hen's egg, felt in 
the lower outer quadrant of the right breast. Marked tender- 
ness present. The rest of the breast is not full and is not 
tender. Over the lower portion of the breast where the ice 
has been there is a definite red area. The bowels moved twice 
this morning. Because of the severe headache which she has 

389 



390 CASE HISTORIES IN OBSTETRICS. 

had she was given an aspirin tablet gr. v repeated twice at 
two-hour intervals with marked relief. Baby is to nurse on 
the left breast until a home modification can be made up. 
Baby is not to be put back on the right breast to-day. Ice- 
bag is to be continued as before. 

On the twenty-third day morning temperature normal, 
pulse 66. Breasts are not full. No pain. Right breast 
apparently accomodating itself to the fact that it is not being 
nursed as the milk is leaking away. Breast still shows a 
definite lump in the right lower quadrant but no tenderness. 
Baby to nurse on this breast at noon. Baby nursed well and 
seemed satisfied. Ice-bag is omitted. 

Twenty-fourth day the baby is nursing regularly every two 
hours from the breasts. From the right breast the baby is 
not satisfied and the breast does not fill up between nursings. 
Baby nursed the right breast for ten minutes and then was 
given a supplemental feeding of half an ounce of the modi- 
fied milk. 

On the twenty-fifth day more milk came into the right 
breast. Baby obtained two ounces. There is no tenderness 
and now no lump in the breast. Patient is up and about the 
house and seemingly perfectly well. 



MASTITIS AND BREAST ABSCESS. 391 

Case 65. Breast Abscess. Incision Under Ether. 
Patient was seen for the first time August 21st. She had a 
normal delivery July 4th, and made an excellent convales- 
cence. She nursed her baby and was discharged from the 
hospital July 17th well. At no time while she was at the 
hospital did she have any difficulty with the breasts. She 
has nursed her baby regularly and the baby has done well. 
She had no pain in the breasts until ten days ago when her 
right breast began to feel ''sore" to the touch. She says 
there was no crack in the nipple. She was advised by friends 
to rub the breast and for the last four days she has rubbed it 
morning and night with warm lard. Condition has become 
steadily worse and she now comes to the hospital for advice. 
She says the baby refuses the right breast and that it has not 
been nursed for forty-eight hours. 

Examination shows the right breast to be nearly twice as 
large as the left. In the inner upper quadrant there is a red 
area the size of a silver dollar. The breast is tender to pal- 
pation and over this red area the skin pits on pressure. 
Distinct fluctuation is present. Temperature 100°. Pulse 
98. 

Diagnosis: Breast abscess. 

Treatment: Immediate incision advised. 

She was not prepared to stay in the hospital to-day but 
promised to return to have the abscess opened the next 
morning. 

August 22. Her temperature this morning was 102.5°, and 
her pulse 120. She was given ether. Breast scrubbed up 
with soap and water and preparation finished with alcohol 
70%. A three-inch radiating incision was made in the middle 
of the mass and much green pus evacuated. Smaller cavities 
broken up with the finger so that there was only one large 
cavity present. The cavity was wiped out with dry gauze 
and packed wide open with a sterile dry gauze dressing. A 
dry dressing applied and a supporting binder was put on. 

August 23. Temperature this morning was 99.4°; pulse 
94. She has no pain in the breast and palpation over the 
breast does not cause her pain. Night temperature 102°; 
pulse 105. Bowels moved this morning. 



392 CASE HISTORIES IN OBSTETRICS. 

August 24. Temperature 98.6°; pulse 82. Night tem- 
perature 99°; pulse 88. From then on she ran absolutely no 
temperature and her pulse steadily dropped. The baby is 
nursing on the left breast alternating with bottle feeding. 

August 28. To-day is the sixth day since the abscess was 
opened. The dressing had stained through and the odor to 
the discharge became marked. The dressing was then taken 
off. Gauze packing removed without any pain and the 
cavity presented an absolutely clean granulating area. No 
necrotic tissue present. Cavity again packed with dry gauze 
but much less in amount used. 

The patient has been up and about the ward for the last 
three days. No tenderness in the breast, and practically no 
induration. 

August 29. The dressing was done to-day. Cavity clean. 
No odor to the dressing. Cavity distinctly smaller. She 
was discharged to the out-patient department where the 
abscess cavity was to be dressed daily. 

September 26. She has reported as requested at first daily, 
then as the wound healed every third or fourth day. The 
cavity gradually closed until to-day the wound is practically 
healed. 

October 10. She reports at the clinic to-day and says the 
wound has been healed solidly the last ten days. No dressing 
over the breast. No milk in the breast. Baby is nursing 
the other breast and every other feeding has the bottle. 

April 15. She reports to-day, six months after the last visit. 
Milk in the past few days has returned in the right breast and 
she was advised to resume nursing from it. The scar is solid 
and no induration about it. 



MASTITIS AND BREAST ABSCESS. 393 

Case 66. Acute Mastitis. Lactation Stopped. June 
6. Patient is twenty-eight days delivered and has been up 
and about her home for the past week. Has been nursing her 
baby and the baby has been doing well. There has been no 
tenderness in the breasts. On the third and fourth days the 
right nipple was slightly tender but with applications of com- 
pound tincture of benzoin after each nursing healed quickly 
and soon became normal. On the morning of the 28th day 
patient had a chill and complained of severe pain and tender- 
ness in the right breast. Temperature when the nurse tele- 
phoned was 99° and pulse 100. I saw her within two hours 
and she then had a temperature of 103.4°, pulse 120. She 
complained of a very severe headache and was aching all 
over. Face is flushed. Physical examination of the abdomen 
negative. Heart and lungs negative. Left breast is normal. 
Examination of the right breast shows no redness. On pal- 
pation no lump made out but exquisite tenderness is present 
throughout the entire breast. Baby is taken at once off this 
breast and ice-bag was ordered to be put constantly on the 
breast. Baby is to continue nursing from the left breast. 
The bowels were opened with licorice powder. 

June 7. Temperature 101.4°, pulse 96, at nine this 
morning. Breast is full. Not as tender as yesterday. A 
definite lump, size of a pigeon's egg, is present in the right 
outer quadrant of the right breast. With a sterile English 
breast pump I drew off two bulbfulls of milk, which gave her 
distinct relief. There is a slight suggestion of edema over the 
mass but nothing absolutely diagnostic. Her bowels have 
moved three times since the last visit. Ice has been kept on 
the breast continuously. Temperature at 12 noon 102.4°, 
pulse 96. Temperature at four this afternoon 100.4°, pulse 90. 

June 8. Telephone message from the nurse this morning 
saying the temperature is 98.6°, pulse 72. The patient is 
feeling very much better. No headache. Breast very much 
less tender. Right breast is very full and tense and I ordered 
that two bulbfulls of milk be pumped out with a sterile breast 
pump. Ice was ordered to be continued to the breast. 

June 9. Morning temperature 97.6°, pulse 70. 12 o'clock 
temperature 99.4°, pulse 80. Breast slightly red, due probably 



394 CASE HISTORIES IN OBSTETRICS. 

to the Ice. Entire breast is tender, but most of the tenderness 
is in the mid-axillary line where the ice-bag has gone over the 
breast tissue onto the skin. 

June 10. Telephone from the nurse. Temperature 99.4°, 
pulse 80. Patient feeling very comfortable though the breast 
was very full and hard. I saw the patient at five p.m. Tem- 
perature at four 99°, pulse 72. There was no edema present. 
Breast is tense but no definite lump can be made out, because 
of the fullness. With the aid of the breast pump obtained 
four bulbfulls of milk with marked relief. Highest the tem- 
perature has been at any time during the last two days was 
99.4°, and the pulse has not been over 80. On the whole there 
is a steady tendency downward of the pulse. I decided to take 
off the ice and two hours later to put the baby to the breast. 

June II, Baby nursed well last night and this morning 
from the breast. Temperature 97.6°, pulse 70. Patient is up 
and about her home. ^ 

June 17. Left nipple became tender and she again com- 
plained of much pain in the right breast. Nothing definite 
to be felt on examination. Her husband was very much 
against her continuing nursing. She was in poor physical 
condition and she herself was also very much averse to 
nursing. Because of the fact that she had several flareups 
with her first nursing and had had this severe one and another 
threatened one now, I agreed to stop nursing. Baby immedi- 
ately put on modified milk from certified dairy. Ice was now 
put on both breasts. Breast binder was put on for support 
only. To-night she was given codeia gr. 1/2 because of pain. 

June 18. Breasts have filled up but very little. There is 
no tenderness present but there are lumps in both breasts. 

June 19. Temperature normal. Pulse "]2. Breasts are fill- 
ing up but little. Lumps present are not tender. Ice has been 
taken off the breast but the breast binder is kept on for support. 

June 21. Breasts are now growing smaller. Very little 
milk in them. They are soft. Lumps are not tender. Milk 
is drying up satisfactorily. 

June 25. Temperature is normal. Breasts are soft and 
flabby. There are no lumps present and but a few drops of 
milk can be expressed from either nipple. 



MASTITIS AND BREAST ABSCESS. 395 

Case 67. Mastitis. Breast Abscess. Bier Suction 
Bells. June 2 1 . Patient presents herself at the office giving 
the following history : — Four months ago she had her fourth 
confinement. Her convalescence was normal. Three weeks 
ago the right nipple became very tender and she noticed a 
crack in it and at two different times saw blood coming from 
this crack. She did not do anything for this condition and 
continued to nurse from this breast. The next day the whole 
breast became tender with shooting pains in it. That evening 
she says she had a chill. Seventeen days ago she saw a 
physician because the breast pained her more and more and 
because the baby would not nurse from it. This physician 
told her that she had an abscess in the breast and advised 
her to let him lance it. She says he ''froze" the breast and 
then lanced it, but no ''matter" came out. Since the breast 
was opened she has not attempted to nurse from it but has 
used the breast pump to milk out the breast two, three or 
four times a day depending upon how full the breast was. The 
breast pump she says was not boiled. The milk she obtained 
she gave to the baby for the first day, but as he vomited it 
once and finally refused to take it she gave up trying to give 
it to him. For the past ten days she says there has been a 
lump in the lower and outer part of the breast. Her physician 
told her that this was due to the backing up of the milk and 
told her to rub it with hot camphorated oil three times a day. 
This she says she has done up to yesterday when the tender- 
ness was so great that she stopped. She also says that there 
is much throbbing in the breast. 

Examination shows the breasts to be large and pendulous. 
The left is normal. In the upper outer quadrant of the right 
breast is a radiating incision partially healed, three-quarters 
of an inch long, part of which is in the areola. From this 
incision can be pressed out a few drops of pus. There is a 
slight amount of induration present about this incision. In 
the outer lower quadrant is a mass the size of a child's fist. 
The skin over this mass is reddened and marked edema is 
present. Definite fluctuation is found. Tenderness over 
this mass is great. Temperature is 100.6°, pulse no. 

The diagnosis of another abscess is evident and the pus 



396 CASE HISTORIES IN OBSTETRICS. 

must be evacuated. Treatment. In the region of the mass 
the breast was cleaned up with 70% alcohol and with ethyl 
chloride local anesthesia, a stab incision was made directly 
into the middle of this mass and about half an ounce of thick 
greenish pus was let out. 

An eight-inch Bier bell was put on this breast and suction 
was carried on for five-minute periods, with three-minute 
intervals four times and much bloody pus from the stab 
incision and some milk from the nipple was withdrawn. Only 
a few drops of pus came from the first incision. The suction 
caused no pain. A sterile dressing was placed over the 
incisions and a supporting binder held the breast well up on 
the chest with great relief. 

June 22. Reports at the office. Slept well last night. 
No pain in the breast and no throbbing. Temperature 98° 
and pulse 80. Dressing taken off and very little discharge 
present on the dressing. Redness is distinctly less. No 
tenderness present. The mass is about the same size as 
yesterday. The Bier bell was put on for five periods of four 
minutes each with two-minute intervals. About three ounces 
of milk were withdrawn from the nipple as a result of the 
suction, but no pus came from the incision. 

June 23. Breast is causing her absolutely no discomiort. 
Is discharging very little. Temperature 98.6°, pulse 88. 
There is no redness present. No tenderness except on very 
deep pressure. Mass in the breast is distinctly smaller than 
two days ago. Bier bell put on for four periods of five minutes 
each with three-minute intervals. No pus but a small amount 
of straw colored serum obtained and about one ounce of milk 
from the nipple. 

June 24. Temperature 98.2"^, pulse 82. There is no 
discharge on the dressing. There is no redness and no edema. 
No tenderness present. Induration is much less marked than 
yesterday. Bell put on for four-minute periods five times with 
two-minute intervals. Only a small amount of yellow serum 
from the stab incision obtained. Examination of the milk 
under the microscope shows many leucocytes to be present. 

June 26. Temperature 98.6°, pulse 80. Few drops of dis- 
charge on the gauze dressing. The mass is growing smaller 



MASTITIS AND BREAST ABSCESS. S97 

and there is apparently much less milk in the breast, as suction 
drew off but about one-half ounce. Bier bell put on four 
periods of five minutes each with two-minute intervals. 

June 28. Temperature normal, pulse 76. No discharge 
on the dressing. Induration is growing steadily less. Bell 
put on three periods of five minutes each with two-minute 
intervals. Only a few drops of serum came from the incision. 

June 30. There has been a steady improvement. Tem- 
perature normal. Pulse 76. No pain in the breast and no 
discharge. Practically no induration present about the in- 
cision. Examination of the milk under the microscope shows 
no leucocytes. Patient advised to put the baby to the breast 
twice to-day and before she reports at the office in two days 
to put the baby regularly back onto the breast. Bier bell 
put on to-day for three periods of five minutes each with two- 
minute intervals. 

July 2. Patient reports over the telephone that the 
incisions are healed, that there is no tenderness in the breast 
and that she can feel no lump. Baby is nursing regularly 
from it and apparently is satisfied. 

Summary of Mastitis and Breast Abscess. 

Reference to the histories of these four cases and of others 
in the text make it very evident that a mastitis may appear 
at any time while a woman is nursing. This is true, and this 
possibility of a patient having an acute fiareup while she is 
nursing must always be kept in mind. With tender, cracked 
nipples the danger of infection is always greater, but it is not 
unusual for a mastitis to appear where there is no demonstrable 
crack or when there has been no tenderness on nursing. 
: The typical onset of an acute mastitis is seen in Case 64. 
A sudden chill, a severe headache, a rise in temperature and 
pulse far out of proportion to what one finds on physical 
examination is the usual story. In the first few hours the 
breast usually is tender, how tender it is depends upon the 
nervous makeup of the patient. In some cases patients will 
scarcely allow one to palpate it at all ; in others the tenderness 
is only appreciated on deep palpation. Usually in the first 



398 CASE HISTORIES IN OBSTETRICS. 

few hours no mass is felt, but within twelve a definite lump is 
palpable, of varying size depending upon the severity of the 
infection and the speed with which treatment has been begun. 
The diagnosis of acute mastitis made, the treatment as above 
described should be begun at once. The patient should go to 
bed. The baby must be taken off the breast. An ice-bag 
is placed at once on the breast where the point of tenderness is 
greatest. If the entire breast is tender and no one point more 
tender than another, then one ice-bag will not thoroughly 
chill the breast tissue and a second must be added. With a 
high temperature, an average sized ice-bag stays cold about 
one hour. If one uses the largest sized bags, the weight of the 
ice may cause the patient much discomfort. Many times 
one can arrange two small bags to better advantage than one 
large one. Fill the bag not more than three-quarters full, 
screw on the cap lightly and then squeeze out the air within 
the bag. This adds much to the comfort of the patient 
because the bag stays on the breast more closely than when it 
is balooned up with air. The ice-bag is kept in place by a light 
supporting binder. Care must be taken to have the ice-bag 
on the breast tissue and not on the ribs. More than once 
have I heard patients complain for days after the ice-bag was 
removed of the pain it caused because of carelessness in 
placing the bag by the nurse or attendant. Occasionally the 
ice freezes the skin and blebs may appear. In cases where 
the skin is very delicate and very tender a layer or two of 
gauze must be placed over the skin to prevent freezing. For 
the headache and general malaise which is so often an accom- 
paniment of this condition, aspirin gr. v every two hours for 
three doses or a so-called migraine tablet will help. The 
bowels should be opened but not purged. I never use mag- 
nesium sulphate in an acute mastitis, — it purges the patient 
too much and without a doubt upsets the stability of the milk. 
Cascara or licorice powder followed by an enema in the 
morning is sufficient. 

The prognosis in these cases, properly treated, is excellent. 
Usually within forty-eight hours, occasionally seventy-two, 
the temperature drops to normal. To be certain that all 
danger is over the pulse must also drop. Again and again have 



MASTITIS AND BREAST ABSCESS. 399 

I seen the temperature drop from 102° to 99°, occasionally 
to fiat normal, but the pulse has only come down to between 
90 and 100 when the patient's normal rate is about 70. In 
such cases watch carefully for further developments for if 
the pulse stays up it is the strongest evidence one can have 
that infection is still present. 

As the breast is not nursed it shortly becomes full and 
uncomfortable. The more closely you approach absolute 
rest for the breast, the better it is. Not infrequently, as in 
Case 64, the breast begins to leak out milk and the acute 
distention is thus overcome. If it does not begin to leak and 
the discomfort is great, then pump out a bulbfull, possibly two, 
of milk, with an English breast pump. Carefully used, the 
breast pump is of the greatest help ; carelessly used, as in Case 
67, a source of much harm. The breast pump must be boiled 
each time before it is used. It is then cooled and put on over 
the nipple at right angles to the nipple and the breast tissue. 
Care must be taken not to have the edge of the flange press 
too strongly on one part of the breast tissue so that it stops 
the flow of milk from the ducts beneath this point of pressure. 
Allow the rubber bulb which was squeezed down before the 
pump was put on to pull out gradually. Do not work this 
rubber bulb in and out. It is surprising to see the relief that 
the removal of even one bulbful of milk gives the patient. 
' In cases where the pulse and temperature fall to normal 
within twenty-four hours of the onset, the baby usually may 
be put back on the breast at the end of the second twenty- 
four hours provided of course the temperature and pulse 
stay down in the interim. 

All patients having a breast upset should at once be put 
on a four-hourly chart. 

Usually the tenderness disappears gradually as the tem- 
perature comes down; the mass, however, is much slower to 
go. In Case 64, the lump did not entirely disappear for nearly 
four days. Where there is no tenderness and the mass still 
persists, gentle massage towards the nipple while the baby is 
nursing will many times hasten its disappearance. 

In Case 66 I felt that I put the baby back on the breast too 
soon but one never can definitely say whether it was that or 



400 CASE HISTORIES IN OBSTETRICS. 

that the patient had another flareup six days after the baby 
was nursing. If a breast clears up it clears up absolutely; 
there should be no doubt in your mind at all. If there is 
doubt, the chances are that this acute mastitis has gone or 
is going on to abscess formation. If there is doubt boil a 
hypodermic needle and plunge the needle, after the skin has 
been sterilized into the midst of the mass. The needle used 
in such a case must be of larger calibre than the usual 
hypodermic needle for with a small needle it is difficult to 
suck up pus into the barrel. If the mass persists, with even 
only a slight rise in temperature and the pulse also remains 
up, there probably is pus present. Edema of the skin over 
the mass has always been, in my experience, absolute proof 
that pus is beneath. Edema is not always present where 
pus is, but when edema is present, pus also is. 

If pus is present it must be evacuated at once; there must 
be no delay. Never watch a breast twenty-four hours or 
forty-eight hours when you have made a diagnosis of breast 
abscess hoping that it will disappear spontaneously. It will 
not and your delay simply allows more destruction of tissue 
to take place. Cases 65 and 67 show the three methods of 
treating breast abscesses. The first is the open surgical-, the 
second is the so-called medical incision, the third is Bier's 
hyperemic method. If one does not mean to use Bier bells, 
the small medical or stab incision should never be used. 
Case 67 shows the bad results which may come from this 
method, — I should say the usual result which follows its use. 
Its use is only mentioned to be condemned. The neglected 
breast abscesses which are so frequent in out-patient clinics 
come from this method oftener than from any other. 

Bier*s method of treatment by increased hyperemia is 
excellent. The objection to it is the cost of the apparatus 
for the few cases that one private physician sees. This, 
therefore, leaves but the open surgical method for the great 
majority of cases. 

Every patient having a breast abscess should be etherized, 
to have the abscess opened. Satisfactory results are not 
obtained if this is not done. The breast is first washed up 
with soap and water and then carefully wiped off with 70% 



MASTITIS AND BREAST ABSCESS. 4OI 

alcohol. A radiating incision is made in the midst of the mass. 
Do not incise the areola for the pigment of the areola follows 
out the incision when healed. But if the abscess cannot be 
properly drained without cutting into the areola do not 
hesitate to do so. The object of a radiating incision is so that 
as few milk ducts as possible may be damaged. The length of 
the incision depends entirely upon the size of the mass, — 
the cavity must be laid wide open so that perfect drainage 
will occur. The pus is evacuated and the cavity is wiped 
out with dry sterile gauze. The many little pockets of pus 
which are always present are broken up with the finger. Do 
not put hydrogen peroxide into the cavity. Much more harm 
is done by further spreading the infection than any possible 
good which may come from its use. If you wish, wipe out 
the cavity with gauze soaked in alcohol 70% but even this is 
not necessary. Pack the cavity firmly and evenly with dry 
sterile gauze. There is no better stimulant for such a cavity. 
A dry sterile dressing is then put in place over the incision 
and the breast is supported by a firm but not tight bandage. 
A glance at the history of Case 65 shows what commonly 
happens in an abscess treated in this way. The marked drop 
both in pulse and temperature always comes if the abscess 
is opened widely enough. The marked rise the evening of 
the day this abscess was opened is unusual. A rise often 
occurs but not so marked as this patient showed. The drop 
in the pulse rate is most characteristic and if healing goes on 
well there is no further rise, but if there is any backing up or 
extension of the abscess the pulse at once rises, usually before 
the temperature. 

The dressing is not disturbed for from four to six days. 
The outside dressing is changed as often as is necessary to 
absorb the discharges. In this case I left the first dressing 
untouched longer than usual because of the marked scepticism 
of two graduate students. The gauze, after this length of 
time, is removed without the slightest pain and in all cases 
the cavity is found filled with clean red granulation tissue in 
marked contrast to the dirty necrotic tissue seen when the 
cavity was opened. If the gauze is removed on the second or 
third day sufficient time has not been given for the granula- 



402 CASE HISTORIES IN OBSTETRICS. 

tions to grow, and the removal of the gauze at this time is 
always painful as are the packings for the next few days. A 
daily dressing is done after the first packing is removed. At 
the second dressing much less gauze is packed into the cavity. 
Experience will tell one how much to put in. The entire 
cavity must have firm pressure on it with the gauze. In 
one's own practice one should never have neglected abscesses 
so long that more than one incision becomes necessary. But 
should one meet an abscess so large that one incision will not 
drain it properly do not hesitate to make a second. The 
lower incision should be so placed that the best drainage 
possible will occur. Do not use rubber tubes for draining 
these abscesses. They are in no way as efficient as gauze. 
They become quickly blocked and where they touch the 
cavity and at the edges of the incisions, the granulations 
become sluggish and dirty. 

The induration about the cavity gradually disappears and 
the cavity rapidly decreases in size but the final healing is 
many times very slow. Occasionally healing is delayed by 
the constant discharge of small amounts of milk. This con- 
dition is called a milk sinus. It is annoying, for it prolongs 
the healing. It is best treated by being left alone or at most a 
small pad is put over the sinus and moderate pressure applied. 
The sinus may last for weeks before it finally ceases to dis- 
charge, but one can tell the patient with assurance that it will 
close. There is no reason why nursing on the sound breast 
should not be continued. 

Treatment of breast abscesses by Bier's suction method has 
not gained favor in this country. The only objection to it 
is, as already mentioned, the cost of the apparatus. For a full 
consideration of this method the reader is referred to an article 
in the Boston Medical and Surgical Journal, Vol. i6o, No. 19, 
pp. 601-608. 

In this method if there is pus present it must be evacuated. 
Do not think that the increased hyperemia will absorb the 
pus. In marked distinction to the open surgical method the 
incision here is simply a stab incision made under local anes- 
thesia. 

The advantage of this method is that the functioning of 



MASTITIS AND BREAST ABSCESS. 403 

the breast is usually continued. This is well shown by Case 
67. Here there was an interval of nearly a month before the 
baby again nursed, but all this time milk remained in the 
breast. The baby was not allowed to nurse until the pus 
cells disappeared from the milk as shown by microscopic 
examination. This return to nursing after the open surgical 
method also occurs, but not so frequently as with the Bier 
method. 

Breast abscesses will occur with the most careful physicians 
and nurses, but the more care that is given the breasts, the 
quicker ice is applied to the breast when a mastitis occurs, the 
less frequently will an abscess appear. It is unfair to put 
the blame of an abscess on a nurse provided she has notified 
you the moment the first pain and tenderness in the breast 
appeared. The responsibility after this is yours and for the 
good or bad result you alone are held responsible. Unceasing 
vigil during the nursing period alone will stop the appearance 
of abscesses. Patients must be warned to report at once any 
pain or tenderness that they may have in the breast during 
the nursing period. Make them realize that you want and 
will accept the responsibility of their condition only with the 
understanding that you are to be told of the first indica- 
tion of trouble. 

The method used to dry up the nursing breasts is seen by 
reference to Cases 66, 71, 75. It is essentially to leave 
them alone. As the breasts become distended and uncom- 
fortable an icebag is put on each breast. The comfort that 
this gives the patient is great. A binder is applied for support 
only, not for pressure. If the pain is severe and the patient 
is unable to sleep codeia may be given ; morphia practically 
never is needed. The bowels are kept open but not purged 
and the patient takes what fluids she wants. In nearly ten 
years work I have never in private practice ordered magnesium 
sulphate, put on a tight, so-called Murphy binder, or limited 
the fluids ingested when the breasts were being dried up. 
Leave the breasts alone is all that is necessary. If the breasts 
are not nursed they at once appreciate this and stop secreting. 
For twenty-four, occasionally forty-eight hours, the breasts 
are uncomfortable, sometimes even very tender. The patient's 



404 CASE HISTORIES IN OBSTETRICS. 

comfort is much increased if a bulbfull or two of milk is 
pumped out from each breast by the breast pump. The 
objection to this is that it stimulates the breast and prolongs 
the process of drying them up. But if haste is not essential 
the comfort of the patient is much increased. 






SECTION XX. 

HEART DISEASE IN PREGNANCY. 

Case 68. Pregnancy with Mitral Regurgitation. 
Normal Delivery. November 26. The patient is seen 
for the first time to-day. She is referred by her family 
physician for decision as to whether she should be allowed 
to go through her present pregnancy, which is some six weeks 
advanced, or have an abortion done at once because of the 
marked mitral regurgitation which she has. He says she 
has never had any broken compensation. The patient is 
thirty-eight years old. She has had four pregnancies. All 
normal deliveries. On the second and fourth she had severe 
post-partum hemorrhages. In the latter part of the fourth 
pregnancy, two years ago, she developed, she says, "kidney 
trouble and some heart trouble." Her last menstruation 
occurred on October 8th. It lasted nine days, which was 
longer than the usual length of her periods. Her September 
period was normal in every respect. On November 8th she 
had a very slight flow for a few hours, which necessitated her 
wearing a napkin for one day. She says that since her first 
baby was born she has worn a pessary for a retroversion and 
that she felt sure she would not become pregnant as she 
never had before while the pessary was in place. As an ex- 
cellent physician, one in whom I had every confidence, had 
examined her within a week and told her he could not make 
a diagnosis of pregnancy, but that the uterus was in good 
position by the pessary, I did not examine her at this time. 
Her pulse when I first saw her was 100, regular and of full 
volume. Blood pressure 120 mm. of Hg. Last June she was 
examined by an internist and she still considers herself un- 
der his care. I told her that I would not consider an abor- 
tion until this physician examined her heart again. If he said 
that she should have an abortion done I would do it, but only 
after a consultation with him. If she is pregnant, and she 

405 



406 CASE HISTORIES IN OBSTETRICS. 

thinks she is, she will be due for delivery the week of July 
ii-i8th. 

She went at once to see her medical adviser. He said, 
after a complete physical examination, without any hesitancy, 
that she need not have an abortion done, that with careful 
management she could go through her pregnancy probably 
without too great a risk; that when he saw her last June 
she showed a small amount of albumin and a few casts in 
her urine but that he did not think an abortion indicated 
especially as she is so situated that every safeguard can be 
thrown about her. Both she and her husband accepted 
gladly this advice as neither had any desire to have an abor- 
tion performed. She is to send in a specimen of her urine 
from the twenty-four hour amount each month up to the 
sixth month, than every two weeks and the last month of 
her pregnancy once a week. Her heart at the present time, 
the consultant said, was well compensated and needed no 
stimulation. He has asked her to let him examine her heart 
once a month during the first months of pregnancy. She is 
to rest with her clothes off for at least an hour after lunch 
each day. Is to avoid going up and downstairs. She is to 
walk only on level stretches and slowly. The slightest un- 
toward symptom she is to report, if she cannot reach him, 
to me. 

December 4. She telephones that a varicose vein which 
she has had for years in her right leg is giving pain. Ex- 
amination at her home shows no tenderness except on deep 
pressure over the saphenous opening of the right leg. The 
vein is prominent in the upper third. There is no indura- 
tion present and no edema of the leg. Temperature is 
98.6°, pulse ']2, The leg was bandaged from the toes to the 
groin with a three-inch flannel bandage cut on the bias. 
For twenty-four hours, she was told to stay upstairs but was 
allowed to go about this floor. Her heart was listened to at 
this time and a loud systolic murmur found at the apex, 
transmitted to the axilla. The pulmonic second is sharp, 
and much louder that the aortic second. No enlargement is 
made by out percussion. Blood pressure is 124. 

December 7. The patient telephones this morning that 



HEART DISEASE IN PREGNANCY. 4O7 

her maid is unable to put on the flannel bandage satis- 
factorily and she asks if something cannot be done. She 
was at once measured for an elastic stocking to run from the 
ankle as far up in the groin as is possible. 

February 21. The pessary to-day found held tightly in 
the vagina. The anterior arm impinges on the urethra. 
The uterus is out of the pelvis and so much enlarged that 
there is no possibility of its becoming incarcerated. The 
pessary was therefore removed. 

March 11. The elastic stocking gave her complete relief 
from all pain. There is no swelling or tenderness in either leg. 
Examination of the heart shows no change from the first 
examination. There are no rales in the lungs. No edema of 
the legs. Blood pressure is 130. A month ago she gave up 
drinking the one cup of coffee she had in the morning as she 
thought it caused a dull ache over the heart. Since she 
stopped it the ache has disappeared. Her urine has been 
normal at each examination. 

May 3. She reports to-day at the office. She is feeling 
well except for an occasional sensation of fullness and dis- 
tress about the heart. Her bowels are moving freely. Her 
urine she said the first of the month was a little over four 
pints. It was suggested by her medical adviser that if she 
kept the urine in the vicinity of three pints it would make 
her more comfortable. Blood pressure is 130. Heart sounds 
the same as previously noted. No rales in the lungs. No 
edema of the feet. 

May II. Urine analysis: 24-hour amount 1625 c.c. 
Normal color. Reaction acid. Specific gravity i.oii. Al- 
bumin by heat, absent; by nitric acid, absent. Sugar, no 
reduction by Fehling's solution. Microscopic examination : — 
No casts, pus or blood seen. Large amount of squamous 
epithelium. 

July 6. She has reported as requested and all examina- 
tions have been satisfactory. I saw her to-day at her home. 
Her pulse was found to be 124 to the minute. Heart ex- 
amined. Apex one to two centimeters outside the mamillary 
line. Not heaving or diffuse. Systolic murmur as before. 
Pulmonic second accentuated. All beats transmitted to 



408 CASE HISTORIES IN OBSTETRICS. 

the radial arteries. No rales in the chest. No edema 
of the extremities. 

The reason for this rapid pulse rate I could not determine. 
Her nurse is with her and she is told to take her pulse every 
four hours to determine whether it stays at this rapid rate. 
Palpation of the abdomen : — Large baby, lying in a left posi- 
tion. Head is engaging at the brim and by the fourth ma- 
noeuvre is found to be well flexed. Biparietal diameter is not 
through the brim. Fetal heart is 120 in the left lower quad- 
rant. The placental bruit is very loud also on the left. 

To-day she was put on a three-quarter grain pill of im- 
ported digitalis leaves morning and night for two days, then 
ordered to omit it for two days and then to repeat until 
labor comes on. 

July 7. The nurse telephones this morning that shortly 
after my visit the patient's pulse dropped to 90 and at no 
time since has it been over that. 

July 12. Urine analysis: — Twenty-four hour amount 
three pints. Color normal ; acid in reaction ; specific gravity 
I. GIG, albumin by heat a very slight trace, by nitric acid 
slightest possible trace. No reduction by Fehling's solution. 
Sediment slight. Microscopic analysis: — Few hyaline and 
fine granular casts seen. No blood. Few leucocytes. Few 
large and small round cells. Much vaginal epithelium. 

July 16. Telephone from the nurse at 9:15 p.m. says that 
in the last half hour the patient has had three very hard con- 
tractions and that she thought she was starting up in labor. 
I saw her at ten. She was having no pains and as she had 
no more in an hour she retired. At 2 a.m. July 17th her 
husband called me and said she had just had one hard pain 
and that the ''waters had come." She at once started in 
labor. Fetal heart was regular at I2G and as the head was 
firmly engaged I did not then examine her. Her pulse was 
90 and regular. She was at once shaved and given an enema. 
Her labor was very desultory, pains coming irregularly at from 
ten to forty-minute Intervals lasting from twenty seconds to 
a minute and a half. At five, examination showed the os 
uteri two-thirds dilated, cervix thin. Head can be pushed 
up out of the brim. Liquor Is coming away clear. Fetal 



HEART DISEASE IN PREGNANCY. 4O9 

heart was found to be 160 but regular and while listening to 
the heart the baby was seen to kick vigorously for nearly a 
minute. Fetal heart was now watched very carefully and 
the rate steadily dropped until at the end of half an hour it 
was 120, regular and loud. It stayed at this rate for the 
next hour. When I found this increase in the heart beat 
and the vigorous kicking, I had my instruments sterilized 
at once in order to be ready for any emergency. At eight 
the pains were coming every twenty minutes distinctly 
harder and lasted regularly one minute. Palpation now 
showed the head to be well in the pelvis. Uterus relaxing well 
between pains and not tender. Fetal heart 120; maternal 
pulse 92. At twelve the pains began coming every three 
minutes and changed to typical second-stage pains. She 
was at once put into the left lateral position. Everything 
was ready for delivery. Because of the history of two pre- 
vious severe post-partum hemorrhages and because of the 
cardiac condition I had sent for an assistant to watch her 
heart and to hold carefully and intelligently the uterus im- 
mediately after the labor. At twelve- fifteen the perineum 
showed the first bulging and with each pain she made marked 
progress. She was given obstetrical ether and as the head 
came over the perineum she was for the moment uncon- 
scious. The baby was born at twelve-thirty. It cried at 
once and was in excellent condition. My assistant held the 
uterus down well and there was but slight amount of bleed- 
ing. Patient's pulse did not go over 100. As soon as the 
cord stopped pulsating it was tied and cut. The uterus was 
now reported as contracting poorly and there was more than 
normal amount of bleeding. Her pulse was no. She was 
turned on her back so that the uterus could be held to better 
advantage. At twelve-fifty the placenta came away spon- 
taneously, — intact with all the membranes. She was at 
once given aseptic ergot intramuscularly. The perineum 
showed no fresh tear. She was cleaned up, a sterile pad 
put in place, and put back in bed. The uterus contracted 
only fairly well. Its relaxed periods were longer than one 
liked. Her pulse, however, had dropped to 90. Coincident 
with each contraction she flowed freely. The uterus had 



410 CASE HISTORIES IN OBSTETRICS. 

been held constantly. I now took the uterus. It was large, 
but no clot or blood could be expressed. It continued to 
relax and she was given a second dose of ergot, and ice was 
put to the fundus. With the ice and gentle manipulation, 
together with firm pressure on the fundus when a contrac- 
tion came, the uterus steadily acted better. I held the 
uterus for an hour after the placenta was delivered and at 
no time allowed it to fill up with blood. There continued 
to be more than the normal amount of flow, but her pulse 
chart showed a steady though slow drop. At the end of an 
hour the uterus was not held, but I went back to it every 
five minutes. It continued to act better and half an hour 
later it was left alone fifteen minutes at a time and it did 
not fill up. At four her pulse was ^2 and she was flowing 
only a normal amount. She had taken two cups of chicken 
broth and was in excellent condition. The binder was then 
put on. The baby weighed 9 pounds and 2 ounces. 

9 P.M. Visit. The nurse had just expelled a large clot 
from the uterus. Patient's pulse 90. She has not voided, 
and a secondary tumor mass is found to the left of the uterus. 
She has already begun to be distended. I ordered at once 
that she be given a high hot enema in order to induce her to 
void her urine. If not successful I was to be notified. Castor 
oil, one ounce, to be given about four a.m. 

July 18. Temperature normal, pulse 76. Voided last 
night with the help of the enema and passed much gas. 
This morning had a good result from the castor oil and now 
there is no distension present. Uterus is tender, lochia is 
normal in amount and character. Colostrum is present in 
the breasts and baby is to be put to the breasts every four 
hours. 

August 2. Has made a perfect convalescence. Baby is 
nursing and is gaining. Patient began her leg exercises on 
the fourteenth day, and now is doing them morning and 
night for five minutes. Her heart has acted perfectly well 
the entire time. 

August 6. Vaginal examination to-day shows the pre- 
vious perineal tears; slight bilateral tear of the cervix. 
Uterus in third-degree retroversion. Not tender and by bi- 



HEART DISEASE IN PREGNANCY. 4II 

manual manipulations readily replaced. The pessary which 
she had previously worn was inserted and it held the uterus 
up in excellent position. Three days after she got up the 
pessary was taken out and the vagina inspected; no ero- 
sion seen and it was replaced. The patient is in excellent 
condition and is now referred back to her family physician. 



412 CASE HISTORIES IN OBSTETRICS. 

Case 69. Mitral Regurgitation Complicating Preg- 
nancy. Early Rupture of the Membranes. Voorhees 
Bag. Forceps Delivery. July 25. Patient is referred 
to me by her physician for care during her pregnancy. 
She gives the following history : — Until she was eighteen 
she was always perfectly well in every respect. She 
then had an attack of rheumatic fever and was in bed 
six weeks. Since then she has always had to be careful 
because she was told that one valve in her heart leaked. 
She easily gets out of breath on going upstairs or walking 
up hills, but she can walk slowly long distances without any 
shortness of breath. She has never had to go to bed be- 
cause of her heart. Her feet never swell. Her last men- 
struation was on February 8th and her confinement will be 
due from the I5th-i8th of November. This is her first preg- 
nancy. Examination of her heart showed it to be enlarged 
to the left one finger's breadth outside the nipple line. Apex 
beat is best felt in the fifth interspace. Normal in character. 
Loud systolic murmur is heard at the apex, transmitted into 
the axilla. Pulmonic second is accentuated. Lungs are 
negative. Abdomen was not palpated. Blood pressure is 
no. Pulse is 100 and regular. I went over the hygiene of 
pregnancy with her. Her physician is to watch her heart 
during the remainder of the pregnancy and also is to follow 
the analysis of the urine. 

September 30. Measurement of the pelvis to-day showed 
it to be normal in all respects. She has had no swelling of 
the feet and with care does not get out of breath readily. 
Blood pressure is no. Urinary analyses have all been 
normal. She apparently is in excellent condition. 

November 8. Palpation shows a fair-sized baby. Back 
is on the right, small parts readily felt on the left, head is at 
the brim, freely movable. Fetal heart not heard but motion 
is felt. Vaginal examination shows the head can be pushed 
readily into the brim. Outlet is normal. Examination of 
the heart same as previous note. Apparently well com- 
pensated. Pulse 80. With her physician's consent she was 
put on tr. digitalis gtts. v twice a day. 

November 23. Membranes ruptured November 20th at 



HEART DISEASE IN PREGNANCY. 413 

four-thirty a.m. while she was asleep. She has had no pains. 
Fetal heart is 120, regular in the right lower quadrant. As 
the liquor was coming away freely she was kept in bed. 
This morning at eight the nurse telephoned that her patient 
began to have slight pains at four, that now they were 
coming regularly every twenty minutes and lasting thirty to 
fifty seconds, and that there was no show. I saw her at ten. 
Pulse is 80, good volume and tension and is regular. Pains 
are now coming every ten minutes and last one minute. 
There is a very slight show of blood. Palpation showed the 
position to be a right posterior. Head is well flexed. Bi- 
parietal is through the brim. Fetal heart is found very 
irregular. While I was listening, it dropped to 70 and then 
quickly rose to 180. At once it dropped back to 120 and for 
some minutes it stayed regular at 120. Vaginal examina- 
tion made at once. No cord felt prolapsed. Os uteri 
admits one finger and cervix thick. Head is firmly engaged 
in the pelvis. Fetal heart was now listened to every twenty 
minutes and it remained absolutely regular at 120. At 
eleven the pains were coming every five minutes and lasting 
one minute. Uterus was soft between pains and not tender. 
Fetal heart showed no variation. Maternal pulse was 88. 

At two-thirty she was having pains every three minutes 
which lasted one minute. Vaginal examination : — Os uteri 
dilated no more. Cervix little if any thinner than at the 
first examination. The presenting part, however, is dis- 
tinctly lower. Patient's pulse was now 100. She had now 
been ten hours in labor, which during the last four hours was 
of excellent character, but she had made no advance in the 
dilatation of the os uteri. Her pulse had steadily risen. I 
therefore determined to put in the largest size Voorhees bag 
at once. An etherizer was sent for and as soon as he arrived 
the bag was readily passed through the os uteri and distended. 

The pains stopped for half an hour and then began again 
regularly every three minutes. For a few minutes after the 
ether was given the pulse went to 120 but as soon as she was 
fully out of ether it became steady at 100. 

The bag was expelled at quarter-past eight, having been 
in since quarter-past three, — five hours. The uterus now 



414 CASE HISTORIES IN OBSTETRICS. 

was contracting well every two minutes. It was soft be- 
tween pains, but slightly tender. The fetal heart was found 
to be 130 and the patient's pulse no. Because of the steady 
rise in the maternal pulse, the slight rise in the fetal heart 
and the slight tenderness of the uterus I determined to de- 
liver her at once. I felt that there was less danger in oper- 
ating than in allowing her to go on for several hours more 
with the pulse steadily rising and the uterus beginning to 
become tender. The etherizer was again sent for and by 
the time he arrived all preparations were completed. She 
was scrubbed with soap and water before she was etherized 
so as to shorten as much as possible the etherization. As 
soon as she was under ether the vulva was quickly scrubbed 
with 70% alcohol. In dilating the perineum and determin- 
ing the position a large amount of unmixed meconium came 
away. Fetal heart was listened to by the etherizer and found 
to be irregular and very rapid. The os uteri was fully dilat- 
able and the position determined as an O. D. A. Forceps 
were quickly applied and traction brought the head down- 
ward, the anterior lip alone holding. Strong traction at once 
pulled the head by the cervix and no time was lost in ex- 
traction of the head. The baby was pallid and without 
tone. The heart was beating about 60 to the minute. The 
cord was not pulsating and it was at once clamped and cut. 
The nurse took the baby to resuscitate it in hot water after 
I had drained it. My etherizer told me to repair the per- 
ineum quickly as her condition did not warrant a careful 
repair, her pulse being now 140 and of poor volume. There 
was a tear along the descending ramus on the right and I 
put here two catgut sutures. The perineum had a deep 
second degree tear and I quickly passed three silkworm-gut 
sutures. The uterus was acting well and there was no bleed- 
ing; as she rallied slightly, pulse dropping to 130 and of 
better quality, I waited for the placenta. The etherizer had 
given her 1/20 of strychnia subcutaneously just after the de- 
livery. The baby now was crying lustily and the nurse put 
him carefully away in good condition. The baby was born 
at 9:45 P.M. At 10:05 the placenta came away intact with 
all the membranes. The external sutures were now tied. 



HEART DISEASE IN PREGNANCY. 415 

Ergot was at once given intramuscularly. She was quickly 
cleaned up, a sterile pad put on the vulva and at once put 
back to bed. Hot water bags put about her and the foot of 
the bed raised on chairs. Her pulse now was 130 and she 
was beginning to be restless. There was no external bleed- 
ing and the uterus was well contracted. She was given 1/6 
of morphia subcutaneously and soon became quiet. She 
looked badly, very pale, and her breathing was very shallow. 
Heart sounds however were good and strong and the mur- 
mur easily heard. Pulse remained 130 and of slightly better 
quality. The volume steadily improved, but the rate did 
not drop. This continued until three a.m. when without 
warning she threw up her hands, rolled her eyes about and 
slightly stiffened the body. Pulse at the wrist was im- 
perceptible. Caffein sodium benzoate gr. 1/2 was given her 
immediately. Heart sounds were clear but the murmur 
was faint. Percussion of heart area showed no dilatation to 
be present. In a moment she opened her eyes and said "I 
guess I fainted." Her pulse now felt at the wrist and it 
steadily improved in quality. She again grew restless and 
the morphia was repeated. By half-past four her pulse had 
dropped to no, regular and of much better volume than at 
any time since the delivery. The improvement was held 
and at eight a.m. her pulse was still no, but of good volume. 
She had taken four ounces of hot milk and had not vomited. 
Her condition was satisfactory and I left her, — uterus well 
contracted with normal amount of flowing. The nurse was 
told not to disturb her in any way until after my return in 
a few hours. Neither was the nurse allowed to wash the 
baby. 

November 24. 11 a.m. She has slept at intervals since I 
left. The pulse remained no. She looks distinctly better. 
Color has returned in her lips. The foot of the bed is still 
raised. As she is sleeping, orders were left with the nurse 
not to put on the binder until this afternoon. She is to have 
liquids every two hours. No stimulation ordered. 

5 p.m. Has slept three hours since last note. Pulse 100. 
Temperature 99.6°. Uterus is well contracted and not tender. 
Patient has not voided, but there is no bladder distension 



4l6 CASE HISTORIES IN OBSTETRICS. 

present. Heart sounds are strong and regular. Murmur is 
very distinct and the pulmonic second much louder than 
the aortic. Foot of the bed let down at this visit and there 
was no alteration of the pulse. Baby is in excellent con- 
dition and takes his half ounce of modified milk well every 
four hours. The baby has a small soft resilient mass on its 
left parietal bone posteriorly. 

November 28. Marked improvement. Pulse has dropped 
to 80. Temperature has not been over 99°. Uterus is in- 
voluting well. No tenderness present. The vulva showed 
much edema the first thirty-six hours and when she voided 
there was much burning. The anus was very edematous 
and small linen cloths soaked in equal parts of hamamelis 
and water applied every two hours gave her much relief. 
Milk came in slowly last night and the baby nursed well 
this morning and is now to be nursed every two hours. The 
mass on the baby's parietal bone has increased so that it 
now is the size of a boy's fist. Its edges are limited by the 
parietal bone. It does not go beyond the sagittal or lamb- 
doid sutures. At its outer edges is felt a definite firm ridge. 
No definite fluctuation is made out, but the mass is resilient. 
Diagnosis of a cephalhematoma is evident and the mother is 
told it would disappear with absolutely no treatment, in the 
course of six to eight weeks. 

December 4. Continues to make a good convalescence. 
Temperature at no time over 99.2°, pulse varies from 80-90. 
Uterus cannot be felt above the symphysis. Lochia is slight 
and has a slight odor. Stitches removed. No tenderness 
when the perineum is pressed upon. The result is only fair. 

January 15. She got out of bed on the twenty-first day 
and very slowly resumed her usual routine. The first two 
weeks after she was up she had marked frequency of urina- 
tion and when the desire to pass water came she was unable 
to hold it. This frequency has steadily diminished but even 
now she has not complete control. She complains of much 
leucorrhea, which she says she has always had, but now is 
much worse. Vaginal examination : — On straining slight pro- 
lapse of the posterior wall. Marked prolapse of the anterior 
vaginal wall. The meatus is pouting. The perineal body is 



HEART DISEASE IN PREGNANCY. 417 

only fair. The tear on the right ramus extended close to 
the urethra and the scar is here readily felt. Uterus is 
normal in position and very small. Inspection of the cervix 
shows a bilateral tear with marked erosion of the anterior 
lip which bleeds readily when touched. Cervix touched 
with Churchill's tincture of iodine. She was advised to take 
a two-quart douche of sterile water to which was added a 
tablespoonful of borax, once a day, and at the present time 
to do nothing more. To wait and see how much the tears 
are going to disable her. The baby has done consistently 
well and is on part bottle and part breast. She says she 
does not know when the cephalhematoma entirely disap- 
peared as it was so gradual, but that now it has entirely 
gone and the two sides of the baby's head feel exactly alike. 

April 30. She comes into the office to-day. She has 
complete control over the urine and there is no frequency. 
Her only complaint now is the leucorrhea which she says is 
thick and ropy, but with no color. Menstruation was estab- 
lished in February and is regular, every four weeks, and of 
the same characteristics as before her pregnancy. Vaginal 
examination as before. Cervix again touched with iodine. 

She is still nursing the baby and it is only with difficulty 
that she can come to the office for local treatment. I advised 
her to make the best of the discomfort of the leucorrhea 
and to continue taking her douches. Except for the annoy- 
ance of the leucorrhea she is in excellent condition. 

June 25. The leucorrhea now is very slight. She does 
not' have to wear a pad, and she considers herself per- 
fectly well. Vaginal examination shows the continued small 
uterus in normal position. The erosion on the anterior lip 
of the cervix is much smaller and now does not bleed when 
touched. It was painted again with iodine. Douches are 
to be continued, but she says the past month she has taken 
but one or two. She asked about the necessity of having 
the tears repaired and said that she wanted at least one 
more child. She was advised unhesitatingly not to be re- 
paired for the present and if she had no symptoms from 
the tears not to at any time, surely not until she was 
through having children. I advised her not to have another 



41 8 CASE HISTORIES IN OBSTETRICS. 

child at least for two years. If she then decided to have 
another baby, to see her medical adviser first and let him 
determine the condition of her heart at that time, and 
whether it was safe for her to go through another preg- 
nancy. 

Summary of Heart Disease in Pregnancy. 

The two preceding cases are not extreme types of cardiac 
disease in pregnancy. In both of these cases compensation 
was good and never had been broken. When a patient pre- 
sents herself for care the history whether she has ever had 
any of the acute infectious diseases should be determined. 
If it appears that the patient has had previous cardiac 
disease, the severity of the attack must be carefully in- 
vestigated, — the length in bed and her subsequent dis- 
ability. 

Pregnancy occurring in a patient who has had several 
breaks in compensation is a much more serious complica- 
tion than in one where the compensation always has been 
maintained. A first pregnancy, as shown by Case 69, gives 
a much more serious prognosis than if the patient has had 
several children. It is very difficult to say how any given 
heart will act during labor. If, because of the added strain 
to which it is subjected during pregnancy, a heart acts 
badly, one may be certain that unless the labor is extraor- 
dinarily easy the heart will go to pieces during labor. The 
average medical consultant knows but little about labor and 
the advice he gives is not always the best. The responsi- 
bility for the outcome of the case rests on the obstetrician 
and it falls upon him to lessen the strain on the already 
damaged heart as much as possible. 

With patients who have a cardiac condition, digitalis 
should be given the last month. In one of the above cases 
the tincture was given, in the other a pill from the imported 
leaves was used. The latter is the best form, for if the drug 
is obtained from a reputable pharmacist the results obtained 
are more certain. Throughout pregnancy, careful oversight 
of the patient must be maintained. Rest, sleep and exer- 
cise in moderation are essential. All possible safeguards 



HEART DISEASE IN PREGNANCY. 419 

must be thrown about the patient. Case 68 was able to 
have all possible help and her general condition when labor 
began was excellent. Among the poor, where the con- 
ditions are reversed, it will become necessary more often 
to interrupt pregnancy. The more severe the cardiac con- 
dition, the earlier will it become necessary to perform a 
therapeutic abortion. The more serious the disease the more 
necessary is it to empty the uterus with the least amount 
of shock. In pearly cases a quick vaginal Caesarean section 
causes the least shock while in late cases where there is a 
possibility of obtaining a viable child the classical Caesarean 
section is the operation of election. Had I performed a 
Caesarean section on Case 69, she would be in much better 
condition to-day than she is now. This advice of perform- 
ing a Caesarean section in cardiac cases sounds very radical, 
but I am convinced that a damaged heart will bear a quick 
Caesarean section much better, and the patient will make a 
better convalescence than if she is subjected to labor and 
an operative delivery from below. 

The puerperium in cardiac cases varies in no way from 
normal cases unless the compensation is broken. Then 
special treatment of the heart is indicated. Nursing is al- 
lowed unless it disturbs the patient and keeps the pulse 
rate elevated. Exercises, at first passive, then active, help 
the general condition and should be insisted upon. If by 
them the pulse rate is accelerated and shortness of breath 
follows they must be stopped. 

Pregnancy in patients with serious heart disease should be 
forbidden, but if the patient elects to become pregnant 
knowing the risks entailed, then she should go through it. 
The responsibility lies with the man and the woman, and 
they must not be led to expect that for slight provocation 
the uterus will be emptied. A pregnancy once begun must 
be safeguarded. The discomforts and the expense that a 
pregnancy coincident with heart disease may cause the pa- 
tient are not sufficient reasons for emptying the uterus. Only 
when the life of the mother is endangered can such a 
pregnancy be interrupted. 

Aortic lesions are more serious than mitral ones and mitral 



420 CASE HISTORIES IN OBSTETRICS. 

regurgitation is the least serious of all. The lesion itself is 
not the criterion on which to go. The patient's past history, 
her willingness and ability to do what is right is more im- 
portant. Each case must be judged upon its own merits. 
No rigid rules can be laid down. The one fundamental 
point, however, is that throughout the pregnancy the patient 
must be under constant intelligent oversight, and if com- 
plications then develop they must be dealt with as they 
arise. In the labor one idea must be foremost, to reduce as 
much as possible the work of the heart, and this, therefore, 
means to allow practically no bearing down in the second 
stage. If there is the slightest delay, forceps should be used. 
In Case 68 there was no indication for forceps because there 
was such a short second stage. We were prepared to deliver 
her at once, but it proved to be unnecessary. 



SECTION XXI. 
SCOPOLAMINE AND MORPHINE ANESTHESIA. 

Case 70. Scopolamine and Morphine Anesthesia in 
Labor. July 24. This patient has had a normal pregnancy 
except that she has a very great apprehension of the outcome 
of the delivery. This is her first pregnancy and she is due 
for delivery about August 12th. Her pelvic measurements 
are all normal. Blood pressure is normal and urinary analysis 
normal. 

August 7. This morning about nine the membranes rup- 
tured without pains. An hour later she had her first pain. 
It was very sharp and hurt her much. She started at once 
in good labor, pains coming every five minutes and lasting 
from forty-five seconds to a minute and a quarter. With 
each pain she cried out. Her pulse between pains was 76 
but after each pain it ranged from 90 to 100. Palpation 
showed an O.L.A. position, head low in the pelvis and well 
flexed. Fetal heart was 130 in the left lower quadrant. 
At 10.30 A.M. I gave her 2^^ gr. of scopolamine and J gr. of 
morphia subcutaneously. The room was darkened and she 
was told to try to go to sleep. In the course of twenty 
minutes she became quiet but with each pain would moan. 
When questions were put to her at about 11.30 she would 
answer intelligently but had little recollection of previous 
questions. At twelve noon we noticed that she was becom- 
ing a little restless. At 12.15 ^ second dose of scopolamine, 
^i^ gi*** was given and she again became quiet except when 
the pains were present. The pains now were coming every 
three minutes. Fetal heart was 136 to the minute. Rectal 
examination showed the cervix to be very thin and os dilated 
two-thirds. 

Pains continued coming at three-minute intervals and were 
now lasting a minute to a minute and a half. At one p.m. 
definite bulging was first seen. Marked show. The patient 

421 



422 CASE HISTORIES IN OBSTETRICS. 

now began to strain with nearly every pain. At one- 
twenty she began to be more and more restless and to cry 
out loudly with each pain. At one-thirty on separating the 
labia the child's scalp could be seen. Fetal heart was now 
1 60. I did not care to delay the delivery any longer so under 
ether anaesthesia I did a very simple low forceps. At the 
very end I hurried the extraction of the head as the circu- 
lation in the scalp was poor. The baby gasped at once and 
in a few minutes cried lustily. With the birth of the baby 
large masses of meconium came away. The placenta came 
away intact with all membranes some twenty minutes later 
and a very slight internal tear of the perineum was repaired 
with chromic catgut. 

August 8. Questioned to-day about her labor, she says 
she has very vague remembrance of what went on after the 
first dose of scopolamine. The second injection she does not 
remember receiving and neither does she remember when 
ether was begun, 

August 28. Has made an excellent convalescence. At 
the present time there is no discharge and her condition is 
satisfactory. The baby is nursing and gaining. 

September i. Vaginal examination to-day showed the 
tear of the perineum well healed. Uterus normal position; 
slight bilateral tear of the cervix; nothing on the sides. 
Baby has done uniformly well and both patients are dis- 
charged to their family physician. 

This case is a fairly typical example of the use of scopo- 
lamine. There are certain points in technique in the use of 
scopolamine that must be observed and they are in a word 
these: Pains must be well established in a primipara every 
four to five minutes, in a multipara every five to seven min- 
utes and lasting about thirty seconds. Then 2^0 g^*- ^^ 
scopolamine and ^ gr. of morphia or in some cases j gr. nar- 
cophin is given. Usually the effect from these drugs is seen 
in from fifteen to twenty minutes. A short while later the 
patient's memory is tested by asking some simple pertinent 
question. If she remembers and answers correctly a second 
dose of scopolamine should be given. Usually one-half of 



SCOPOLAMINE AND MORPHINE ANESTHESIA. 423 

the first dose is given but morphia is not repeated. If the 
memory is lost the second dose of scopolamine should be 
held off until by further questioning it is seen that the memory 
is returning. The memory test Gauss insists is an important 
part in the^ technique scopolamine anaesthesia. This condi- 
tion of amnesia should be obtained slowly by repeated doses. 

The furor that passed over this country a year ago when 
the lay press tried to force 'twilight sleep" upon the medical 
profession has to some extent died down but there still are 
a few patients that demand it. It takes from one and a 
half to three hours to get scopolamine acting satisfactorily, 
and it is evident in many multiparous cases, where the pains 
do not come regularly every five to seven minutes until late 
in the labor, that it would be difficult, if not impossible, to 
have the patient sufficiently under the influence of scopolamine 
to be of any value, before the baby was bom. In the above 
case the circulation in the scalp was not good and I hurried 
the delivery. Whether this was a true picture of oligopnea 
or slight asphyxia, which is so common in ** twilight sleep'* 
cases, or whether it was due to the fact that the membranes 
were ruptured and there was some compression of the cord, 
is difficult to say. This condition of oligopnea is one that, al- 
though alarming, is not necessarily dangerous, but means to 
resuscitate the baby must always be present when " twilight 
sleep" is used. Whether or not the use of '' twilight sleep" 
reduces the number of forceps operations that are done, to 
my mind is immaterial, provided the operator knows how to 
deliver a patient carefully with forceps and without tears. 
I am rather inclined to think that the risk of untrained men 
using "twilight sleep" is greater than the risk of these men 
doing a moderately good forceps delivery. 

Up to within a relatively short time ago it was impossible 
to obtain a good preparation of scopolamine. A further 
complication in the use of scopolamine is that the effect on 
any individual patient is always at first unknown and that 
is one of the chief reasons why, in inducing amnesia, the 
doses must be small and given slowly. There are certain 
side effects which sometimes follow the giving of scopolamine. 
The reddening of the face certainly is not alarming. Thirst 



424 CASE HISTORIES IN OBSTETRICS. 

may be most annoying. The motor excitement is at times 
tremendous, necessitating several nurses to hold the patient 
m restraint. Fortunately, this is an uncommon compli- 
cation but no one can foretell which patient will show it. 
The hallucinations do occur but Kronig says that ''these are 
of no material importance so long as the relations of the 
mother do not remain in the room, for these states of excit- 
ability make an unpleasant impression on the family. In 
consequence of these we only carry on the method of ''twilight 
sleep" in cases where the relatives promise to be out of the 
room during the whole time of birth. '* 

It has been claimed for "twilight sleep" that there is less 
frequency of severe perineal tears and if that is a fact it is 
probably due to the complete and slow dilatation of the birth 
canal. The lactation period shows no harmful effects from 
the drug. There are certain definite contra-indications for 
the use of scopolamine. The first and most important is 
where there is primary uterine inertia. Kronig and Gauss 
further avoid using it in the cases where there is disturbance 
of consciousness, high-grade pelvic contractions, illness with 
fever and when communication with the patient cannot be 
had on account of inability to understand the language 
spoken. I have already spoken of the inability to have 
"twilight sleep" satisfactorily induced where labor is rapid. 

Some of the physicians, I do not by any means mean to say 
all, who have taken up twilight sleep, have done so purely 
for commercial reasons. Some who have never had any 
great experience in obstetrics have rushed into "twilight sleep," 
posing as specialists, and these are the ones who have done 
harm to obstetrics and to the placing of "twilight sleep" 
on a definite scientific basis in this country. It has a small 
place in obstetrics and the patient who is high-strung and 
without any nerve force may be helped materially by the 
use of scopolamine, but for the general run of cases I am 
confident that other means of analgesia are much more 
satisfactory. 



SECTION XXII. 
PUERPERAL INSANITY. 

Case 71. Puerperal Insanity. This patient is seen for 
the first time October 28th. She gives the following history 
of her pregnancy : — She is at the end of the seventh month of 
her first pregnancy. Her last menstruation began on March 
19th. She has been perfectly well during her pregnancy 
and has been under no medical supervision. Her menstru- 
ation appeared when she was twelve years old. It comes 
regularly every twenty-eight days and lasts four days. It 
is unaccompanied by pain. She has always been well ex- 
cept for a slight nervous breakdown while she was at college 
three years ago. 

For some unaccountable reason she has reckoned that her 
baby is coming January 24th. If she is right in her dates 
she will be due for delivery the week of December 22nd. 

The remainder of her pregnancy is without note. Exami- 
nation of the pelvis showed it to be normal. 

December 28. Patient started in very slight labor this 
morning at three. At four she went into a private hospital, 
I saw her at nine. She was then having pains every five 
minutes, lasting forty seconds. Pulse is recorded as 60 and 
temperature 98.6°. The membranes ruptured shortly before 
I saw her. Meconium-stained fluid was coming from the 
vagina. 

Palpation of the Abdomen: — Fair-sized baby lying in 
a left position. Biparietal diameter is through the brim. 
Uterus is relaxing well between the pains. Fetal heart is 
1 30 in left lower quadrant. Vaginal examination : — Attempt 
to make an examination caused so much pain that nothing 
was determined and she was at once given primary ether. The 
head was found on the perineum, cervix thick, os uteri 
dilated one inch. She continued in excellent labor. Fetal 
heart stayed regular. At twelve o'clock, patient's pulse had 

425 



426 CASE HISTORIES IN OBSTETRICS. 

risen to 90. Uterus was relaxing well and there was begin- 
ning to be a slight show. Shortly after one she began bear- 
ing down with each pain and there was very slight bulging 
of the perineum. At half-past two her pulse had risen to 
no and the fetal heart was found to be 150. I therefore 
decided to deliver her at once. Preparations were com- 
pleted and she was etherized. The os uteri was not felt; 
it had retracted behind the occiput. The sagittal suture 
was in the antero-posterior diameter. Forceps were readily 
applied and a very easy extraction followed. The baby's 
cord was not pulsating and it was at once clamped and cut. 
The baby was drained, and it soon cried lustily. It was 
given to the nurse and surrounded by blankets and hot 
water bottles. Examination of the perineum showed a 
slight superficial internal tear which was at once repaired 
with one chromic catgut suture. The baby was born at 
3:15 P.M. The placenta came away intact with all the mem- 
branes at 3:45 P.M. The patient's pulse after delivery was 
120. Uterus acted well. She was at once cleaned up, a 
sterile pad was put on the vulva and she was put back to 
bed. Pulse soon dropped to 100. The baby, a girl, weighed 
six pounds and fifteen ounces. I left the patient at half-past 
five in excellent condition. 

January 2. Is making an excellent convalescence in every 
respect. Baby is nursing and is satisfied. The patient is 
talkative and slightly excited. She frankly said she was 
excited. *^I have not quite got hold of myself," she said. 

January 3. 12:30 a.m. Telephone from the hospital say- 
ing the patient is restless and not sleeping and is very talka- 
tive. She was ordered trional gr. x. 

1 :05 A.M. Telephone saying the patient was very much 
worried about something, and wanted to see me at once. 
I saw her at half-past one. She at once began talking very 
rapidly, telling me of the dislike she had for a new nurse that 
had come into her room early in the evening. She said that 
her thoughts were coming fast and that she could not tell 
them all to me. She talked rationally, but very fast. She 
had no hallucinations. Her pulse was 100. A special 
nurse was at once sent for. The patient was given chloral 



PUERPERAL INSANITY. 427 

hydrate gr. x and potassium bromide gr. xl by rectum. 
In the hospital order book it was written that she must not 
be left alone a moment. I made no physical examination 
at this time. The medicine had no effect upon her. She 
talked incessantly and was very restless, sitting up and at- 
tempting now and then to get out of bed. At three a.m. 
she was so noisy and difficult to manage that she was given 
morphia gr. 1/4 subcutaneously. She did not close her eyes 
all night, but was a little more easy to manage after the 
morphia was given. The husband came to the hospital at 
ten and the situation was fully explained to him. I told him 
that at the present moment I was unwilling to say whether 
the condition was simply a sudden burst of excitement or 
whether it was the beginning of a long and serious illness, 
but that it more likely was the latter. The importance of 
having her watched every moment I made very clear to him. 
The question of a consultation with a neurologist I left for 
him to decide, but for the present I thought it unnecessary. 

The patient took a pronounced dislike to the first nurse 
and she was at once displaced for one of more attractive and 
stronger personality. From the husband I found that the 
illness she had had at college had taken the form of severe 
depression; that she never could get through her college 
work, that all her friends were giving her up, and that she 
was of no use in this world. This illness lasted in all about 
six months, but only for one month did she talk of her being 
of no use in the world. 

I determined to continue nursing the baby for another 
twenty-four hours for now she was quiet and rational. Tem- 
perature this morning 100.2°, pulse 96. Pupils are widely 
dilated and react slowly to light. Obstetrically there is 
nothing wrong. Her bowels are moving each day and there 
is sufficient urine. She is to be given a soft solid diet and 
potassium bromide gr. xl every two hours for three doses 
by rectum. 

January 4. Yesterday afternoon as the result of the 
bromide she slept for an hour and last night she slept in all 
six hours. She is taking her nourishment well. She said 
she was seeing myriads of sheep going over the bed and 



428 CASE HISTORIES IN OBSTETRICS. 

walls, that it was not at all unpleasant, for she said seeing 
them soothed her. The baby to-day was given alternate 
feedings of the bottle. 

January 5. She slept in all five hours last night. When 
awake she was quiet. Temperature is normal. Pulse 100. 
Her pupils are widely dilated. She talks quietly and answers 
slowly the questions put to her. She said now that nothing 
was troubling her except one thing, and wanted to know if 
she could speak to me about it. She then went on as if 
prefacing her question, but she had no question to put to 
me. 

January 6. Yesterday afternoon and evening she became 
very restless, and was given forty grains of the triple bro- 
mides every two hours for four doses. She slept last night 
for seven hours. Her temperature is normal. Pulse is no. 
This morning she talked quietly and intelligently for about 
ten minutes and when I was about to go she said, ''There is 
one thing I want to ask you." I told her to ask me and 
she then said, ''That is what I am trying to think, what it 
is. . .. . Qh, yes, I did not want you. ... I won't be so 
ambitious. That little plant over there (pointing to one 
on the table) suggested it to me. I want to go slow. I am 
a bit weary." She then stopped and would not answer any 
more questions. To-day was the first time that this in- 
ability to hold her thoughts came out so clearly. She 
answers questions slowly, but correctly. The baby was not 
put to the breast last night and she did not notice that it 
was not brought to her. I put the baby entirely on the 
bottle to-day. The husband to-day was definitely told that 
the condition was one of so-called puerperal insanity, and in 
all probability it would be three or four months, possibly six, 
before she would be well again, and that he must determine 
whether to keep her at home or let her go to an institution, 
that if she went to an institution she must be committed for 
she was in no condition to go as a voluntary patient. 

January 8. I asked to-day for a consultation with a neu- 
rologist and he saw her this afternoon. She talked freely 
with him, at once placed him as a nerve specialist, but did 
not think it strange he had come to see her. She was very 



PUERPERAL INSANITY. 429 

slow to answer his questions, and at times was unable to 
hold her thought to the question. The consultant con- 
firmed the diagnosis, and went fully with the husband into 
the importance of insistent watching. He told me to make 
use of the bromides as occasion arose, and not to hesitate to 
use hyoscine hydrobromate gr. 1/ 100 in order to quiet her. 

January 1 1 . Each day she is becoming harder to manage. 
Tries constantly to get out of bed. Says she is sure she must 
not talk, — ''must follow the dictates of her heart." Yet 
she talks incessantly. Breasts have dried up without any 
treatment and with no trouble. Her temperature is normal 
but the pulse is 128. Murmur heard to-day over the pul- 
monic area. No enlargement of the heart. Nothing found 
on careful physical examination, except that her pupils are 
still widely dilated. She is sleeping poorly, not more than 
four hours in the twenty-four. With the aid of hyoscine 
she is kept fairly quiet. Up to to-day she has eaten very 
well, but to-day refused absolutely to take anything for two 
or three hours at a time, and then she would take whatever 
was offered her. To-day she would not void her urine for 
twelve hours. 

January 13. Patient moved to-day from the hospital to 
her home. She realized she was at home and tried several 
times to say so, but all we could make out were the words 
**glad" and ''home." She now has absolutely no contin- 
uity of thought. She has frequent outbursts of laughing or 
crying. She is praying for minutes at a time and then be- 
comes silent, and will not show the slightest willingness to 
talk. To-day she began to hold her legs and arms rigid. 
At times she refuses to eat, but in the twenty-four hours she 
gets a sufficient amount of nourishment. When the arms 
and legs are not held rigid they are in constant motion; 
especially marked is the picking of the hands at the bed- 
clothes. 

January 18. Her pulse last night rose to 130. Tem- 
perature 98.8°, respirations 32. Physical examination ab- 
solutely negative except for a slight foul-smelling discharge 
from the vagina. For this she was given a sterile water 
vaginal douche. Pupils are still widely dilated. Knee-jerks 



430 CASE HISTORIES IN OBSTETRICS. 

are present and normal. She is holding her urine longer 
and longer, but as yet she has not been catheterized as a large 
enema has always induced her to void. She has had hyoscine 
generally once a day, occasionally twice and once she had 
it three times in the twenty-four hours. Bromides have 
varied much, — from nothing up to one hundred and forty 
grains in the twenty-four hours. Morphia has been given 
in the last ten days only once, and then only because the 
nurse was unable to manage her, and the husband was away. 

January 23. Patient has slept constantly for the last four 
days, roused only to take nourishment every four hours. She 
is eating from four to six eggs a day, toast, cereal, vegetables 
and the simple desserts, together with at least a quart of 
milk each twenty-four hours. Were it not for the abso- 
lute devotion of the two nurses the amount of food taken 
would be much less, for she has to be persuaded to take all 
of it, and much of the time after it is put in her mouth her 
lips have to be held or she would spit it all out. Her pulse 
to-day is 100, temperature normal, respirations 28. There 
is now no odor to the vaginal discharge which is very slight 
in amount. At times she is incontinent of both urine and 
feces. She has had no drugs to quiet her since the 19th of 
January. 

January 31. She has shown steady improvement the past 
week. The pupils now are normal in size. This morning 
when I saw her she held out her hand to me and tried to say 
something which was unintelligible, and then added "Oh 
well, what is the use anyway." There has been a steady 
though slow drop in the pulse line. This morning it was 
90. She now will take solid food much better than liquids. 
She is on the whole eating excellently. It is harder to per- 
suade her to eat in the mornings than in the afternoons and 
evenings. She now is constantly trying to ask questions, 
but is markedly confused. This morning she tried to get 
up out of bed saying she had been there long enough. When 
she was asked to lie down she did so with no objection. 

February 12. There has been a steady but slight im- 
provement. She is eating splendidly. Bowels move daily 
with two aloin, strychnia and belladonna pills and an enema 



PUERPERAL INSANITY. 431 

in the morning. She has not been incontinent for over 
two weeks. This morning she asked to have her mouth 
washed out, and the nurse suggested that she should brush her 
own teeth, which she at once did. She is less and less con- 
fused, her clear periods are longer and longer and she talks 
intelligently with her husband every day. She asks for her 
mother and father, but has as yet said nothing about her 
baby. She now answers questions with but little delay, and 
does everything the nurses ask her. She is sleeping from 
seven to nine hours without waking at night and has many 
short naps during the day. 

February 22. The night nurse was taken off two days 
ago. My consultant saw the patient again to-day and was 
enthusiastic about her physical condition. He found her 
reactions all present and normal. She, however, would 
answer none of his questions, but remained silent the 
entire time, although before and after he saw her she talked 
freely. She is urged to keep quiet and do nothing but sleep 
and eat. She has had no drugs for the past month. 

March 10. On March first her pulse dropped to 80, but 
from then to now it has steadily risen until to-day it varied 
from 120-140. Beginning yesterday she became dull and silent. 
To-day she is incontinent both of feces and of urine. Pupils 
are again dilated, otherwise physical examination is negative. 

March 17. Two days ago she refused to eat anything, 
and she was put on nutrient enemata twice a day. Yester- 
day she took fifteen ounces of milk by mouth. To-day, 
after much urging, she was forced to take thirty- four ounces 
of milk, six eggs and sixteen ounces of water. She is sleeping 
but three or four hours in the twenty-four. 

March 25. Refuses all food. Holds it in her mouth in- 
definitely and then spits it out. Constantly passing gas, 
feces and urine in the bed, and the nutrients cannot be 
given her. This afternoon, tried to feed her by the stomach 
tube, but she fought so that I could not pass it. She then 
said that she would ''eat something without doing that." 
She immediately did so, but only after much urging. 

To-day she again began to hold herself rigid. She gets into 
one position and stays there for hours or until moved to 



432 CASE HISTORIES IN OBSTETRICS. 

another. She holds her elbows and knees flexed most of 
the time. All passive motion or massage she resists. Respi- 
rations are at times almost of Cheyne-Stokes type. Physi- 
cal examination negative. 

March 2"]. Her father saw her to-day and she recognized 
him, put her arms about his neck and apparently was de- 
lighted to see him. She at once asked him "what are they 
trying to do to me." Told him they were poisoning her, 
and that was why she would not eat better. She then said 
she would eat anything for him. 

March 30. Distinct improvement. Is again eating but 
only when her father feeds her. Is sleeping from six to 
eight hours at night, but none during the day. Her pulse is 
slowly coming down, and this morning it was 100. Usually 
it is about no, of good volume and tension. For the past 
two days there has been present a fine tremor of her lips, 
hands and arms. None of the legs. This morning it is 
much less marked. Pupils have again become smaller. 

April 5. She still has delusions of poisoning, but with 
persuasion they are overcome, and she now eats everything 
that the nurse brings her. Yesterday for the first time she 
mentioned her baby, but before she was answered she wan- 
dered off on to something else. For the last week she has 
been taken out on the piazza daily, and she plainly showed 
she was pleased. She is sitting up in bed to eat her meals. 
She is smiling and talking more and more intelligently. She 
has steadily fought all massage or passive motions. To-day 
she stood up by the bed for a few moments, and then said 
her legs felt ''queer." From this remark we persuaded her 
to let the nurse give her massage morning and night. 

April 10. At times she is quite talkative, but not con- 
sistently clear. She is eating and sleeping splendidly. She 
is inclined to lie constantly with her legs drawn up in marked 
flexion if she is not watched. Whenever I see her she re- 
fuses to answer any questions. Several times at night in 
the past week she has been restless for short periods, throw- 
ing off the bedclothes and attempting to get up. But with 
persuasion and an occasional sharp order she at once be- 
comes reasonable. 



PUERPERAL INSANITY. 433 

April 19. To-day she put out her hand to me and called 
me by name, the first time since early in her illness. She 
talked intelligently, and asked many searching questions all 
of which were answered truthfully. She then said "I wish 
I could have my baby." It was explained to her why she 
could not and she accepted the explanation without question. 

May 6. Marked and rapid improvement. She is walking 
about her home and gaining steadily in every respect. Three 
days ago she showed a definite hostility to her nurse for the 
first time, and the reason for it she told her husband was 
because of the expense of having her. Her husband satis- 
factorily explained to her the necessity of having the nurse 
longer, and then the hostility at once disappeared. 

May 23. The improvement was so great that on the 14th 
she went with her nurse and husband to his father's home, 
where she could be out of doors in the country each day. 
Her baby was there and from all points of view it seemed 
much the best plan. She made the trip with ease and 
everything went well until to-day when the nurse wrote 
*'that there was a marked change in her mental condition. 
This morning she forgot to give the baby her bath even 
though she spoke of it five minutes before. She went for 
the bottle, but forgot to heat the milk. She comprehends 
very slowly what is said to her. She shows no affection for 
the baby. Physically she is doing splendidly, walking well 
and eating and sleeping." 

I telegraphed at once that they should come home for she 
undoubtedly was having a relapse. 

May 25. The husband and nurse brought her home with- 
out any difficulty last night. This morning I found her 
lying quietly in bed, pupils widely dilated. She showed no 
signs of recognizing me. She would answer no questions. 
She would not put out her tongue. Her pulse is 130, of fair 
volume and tension. Temperature normal. Physical ex- 
amination is negative. She has improved markedly in her 
musculature. I now brought up the question of her going 
to an institution until this relapse was over, and the husband 
said he wanted time to think it over. 

May 26. She did not sleep last night at all, but lay 



434 CASE HISTORIES IN OBSTETRICS. 

quietly in bed. It is only with much persuasion that she 
will eat at all. She is incontinent of feces, but holds her 
urine indefinitely or until an enema is given her. Her feet, 
legs, arms, and hands are rigid. Marked but fine tremor of 
the lips and eyelids. Pupils are widely . dilated and react 
very slowly. It is difficult to obtain the knee-jerks because 
of her rigidity. She is making many foolish remarks and 
seemingly does not understand anything that is said to her. 

May 30. Marked improvement the past two days. Talks 
rationally with her husband on all subjects. There is now 
practically no rigidity. She is eating everything which is 
brought to her, but is sleeping only from five to six hours 
in the twenty-four. Pulse is 90. 

June 3. Has improved so much that to-day she sat up 
to eat one meal. Her husband yesterday spoke to her about 
going to the hospital until she became entirely well again. 
She at once fell in with the suggestion for she realizes fully 
the great expense that her husband has been under, and 
says she wants to do everything she can to lessen it and get 
well quickly. When I saw her this afternoon she told me 
she wanted to go to the hospital. 

June 4. This morning when I came for her in the auto- 
mobile she was dressed, ready, and glad to go to the hospital 
where a room had been engaged for her. She walked down- 
stairs and got into the automobile, and with her husband 
and nurse we went out to the hospital. She readily signed 
the necessary papers for admission as a voluntary patient, 
and we left her seemingly very happy to be there. 

The final outcome of this case was that a week after she 
entered the hospital she had a very serious relapse, and for 
some days the physicians were doubtful whether she would 
live. She, however, gradually improved and by September 
was discharged as well. From then to now, over three 
years, she has remained perfectly well. 

Summary of Puerperal Insanity. 

The above recorded case is an excellent example of one 
type of so-called puerperal insanity. The name puerperal 
insanity is given it simply because the mental upset appears 



PUERPERAL INSANITY. 435 

in the puerperium. When it occurs during pregnancy it is 
called gestational insanity, or if during lactation, the insanity 
of lactation. According to the present theories as to the cause 
of this type of insanity it is not thought that pregnancy is the 
fundamental cause. The mental derangement is latent in 
the patient, and anything which upsets that patient's equilib- 
rium will be the exciting cause of the present outburst, but it 
is not to be regarded as the fundamental one. 

In well-marked cases of this condition the diagnosis is 
very easy, but when the symptoms are few and the de- 
rangement is slight the diagnosis is difficult and must not be 
made definitely unless one is positive of the condition he has 
to deal with. The two types that obstetricians usually meet 
are the excited, maniacal, and the depressed, mute type. 
Either type may predominate or there may be greater or 
less fusion of the characteristics of the two types. 

Whether the diagnosis is clear or not a consultation is 
generally advisable with a neurologist in order that the pros 
and cons of treatment may be thoroughly gone into and the 
patient's condition carefully safeguarded. Also the physician 
must protect himself from any possible criticism. The first 
suggestion that the patient may be beginning an upset is 
her wakefulness, or she may make a remark that has no con- 
nection with the conversation that is then going on. Little 
changes from her known previous condition are suggestive. 
These changes may be gradual and difficult to recognize. 
Of the opposite type is the acute onset; the patient in a few 
moments becomes a raving maniac, who may do serious 
damage to herself, her baby, or her companions if not quickly 
restrained. As soon as the diagnosis is made the question of 
institutional or home treatment comes up. There can be 
no argument that home treatment is unsatisfactory unless 
the home is turned into a hospital. The objection that the 
family so often raises to hospital care and the necessity for 
commitment makes the physician many times keep the 
patient at home when he knows she should go to the hospital. 
In the above recorded case the patient's family would not 
listen to the patient going to a hospital. If the patient stays 
at home the necessity for adequate nursing must be in- 



436 CASE HISTORIES IN OBSTETRICS. 

sisted upon. A day and a night nurse, with members of the 
family or the servants to help the nurses, are absolutely essen- 
tial for the management of such a patient. The necessity 
for more nurses may arise at any moment. All orders which 
the physician gives must be written so that there may be 
no misunderstanding. A physician looking after such a case 
must not assume that the nurse will do the proper things 
without orders. The orders must be given to the minutest 
detail. The first and most important order in every case of 
this type is that under no circumstances whatsoever is the 
patient to be left alone. The mere presence in the room of 
the nurse is not sufficient. She must so place herself that 
the patient cannot elude her, for the cunning and alacrity 
with which these patients act when once the impulse comes 
to their disordered mind is surprising. 

Careful nursing is the most important part in the treat- 
ment of this condition. It is upon the nurses that the hard 
work falls. Drugs must be used as little as possible. In 
the above case they were used only when the patient be- 
came so noisy that other patients were disturbed, or when 
there was not enough help to restrain the patient from doing 
herself harm. Food in an easily digested form is the sheet 
anchor in this disease. If the patient will not eat she must 
be fed, either by a stomach or nasal tube. There is no 
room for argument about the necessity for food. Not 
infrequently after the patient is forcibly fed she will there- 
after take the food offered her without resistance. Pro- 
longed hot baths will quiet the patient many times, but if 
the patient is kept at home the difficulty in giving them is 
great unless there is sufficient help. In no type of sickness 
is good nursing more essential. The lack of control over 
the sphincters necessitates constant attention if the patient 
is not to develop serious bed-sores. The musculature may 
be aided by massage and passive motions. When recovery 
starts it usually is progressive; careful oversight in the con- 
valescence is important and the patient must be made to 
realize that she must go slowly and that a slow gradual 
complete recovery is more essential than a quick one. When 
the diagnosis is definitely established the baby should be 



PUERPERAL INSANITY. 437 

taken from the mother's breast. If the baby is nursed a 
few times the nurse must stand close to the baby the entire 
time it is with the mother, for the impulse to destroy may at 
any moment appear, and the baby's life must be safeguarded. 
The husband, as recovery takes place, will ask whether 
other pregnancies should follow. Pregnancy is not the basic 
cause of puerperal insanity. The mother has unquestion- 
ably an unstable mental equilibrium, and any added strain 
may bring on another outbreak, while if she leads a normal, 
quiet hygienic life she may continue for years a useful mem- 
ber of society. If our present theories as to the fundamental 
causes of this type of insanity are correct then she should 
bear no more children. 



SECTION XXIII. 
THE HYDROSTATIC DILATING BAGS. 

Case 72. VooRHEEs Bag. Intermediate Forceps. 
Patient is seen for the first time November 23rd. She says 
that she is t^vo and a half months pregnant, and that she is 
expecting the time of her third period December first. Her 
last menstruation was on September 9th. This will make 
delivery due about the 15th to the 19th of the following June. 

She went through her pregnancy without a great deal of 
difficulty. She was apprehensive and stood the discomforts 
of her pregnancy only fairly well. She has reported each 
month, and has brought in a specimen regularly. From the 
sixth month she has sent a specimen into the office regularly 
on the fifteenth of every month, and has also brought one 
when she came on the first of each month. All urinary ex- 
aminations have been normal. Blood pressure has never 
been over 130. On May 17th measurement of the pelvis gave 
the following results: — crests 28 cm., spines 23 cm., external 
conjugate 19 cm. Fetal heart is heard in the right lower 
quadrant, 120 to the minute. The head is at the brim, not 
engaged. 

June 2. Husband telephones at 10 p.m. saying his wife 
has just told him that for the last two days she has had a 
slight discharge of water coming now and then from the 
vagina. She did not think it was important, and therefore 
had not said anything about it. He says she is having pains 
every eight minutes and he thinks she is beginning her 
labor. I asked another physician to see her at once, as I 
was out of town. He reported at twelve o'clock that the 
cervix was partially taken up. External os admits one 
finger. Head is high. Patient is having definite contrac- 
tions every eight minutes and there is liquor coming away. 
It is his opinion that she is starting in labor. When I got to 
her at half -past two in the morning of June third she was 

439 



440 CASE HISTORIES IN OBSTETRICS. 

having pains only once every half hour and with but very 
slight contractions of the uterus. She was nervous and 
apprehensive. Palpation of the abdomen showed that the 
head was now firmly fixed at the brim, but the biparietal 
diameter was not through the inlet. Her temperature was 
98.8° and pulse 90. I gave her 1/6 gr. of morphia sub- 
cutaneously at once as she was not in true labor. From 
3:30 A.M. until 7 A.M. she slept. At nine o'clock pains 
started in again every twenty minutes, but lasted only thirty 
seconds. There was no show. This continued during the 
morning. Pains came regularly every half hour to twenty 
minutes, but at no time were they at all severe. Uterus re- 
laxed well and there was no tenderness. Patient was not in 
good labor. At 2 p.m. pains started in regularly every eight 
minutes, lasting one-half to three-quarters of a minute. 
Uterus contracted well. Vaginal examination at three p.m. 
showed the head distinctly lower than the physician had, the 
night before, described it. Cervix is thick and the os dilat- 
able one inch. The promontory cannot be reached. Ischial 
spines are prominent. The arch is normal and the tuberosi- 
ties of the ischia are not contracted. From now until nine 
o'clock the pains came steadily at nine minute intervals last- 
ing one minute. The character of the pains was not severe, 
however, but the contractions were good. There had been 
no show and there was very little liquor coming away. Fetal 
heart listened to once an hour and it remained regular. At 
nine o'clock palpation showed that the head had not de- 
scended. Vaginal examination showed that the os uteri 
had dilated no more. The cervix was thick. In over six 
hours there had been no progress and I decided to put in, at 
once, a large-sized Voorhees bag under ether. At 9 45 every- 
thing was ready and she was etherized. Vagina wiped out 
thoroughly with 70% alcohol. Perineum was dilated. Ex- 
amination showed the cervix thick and rigid. The os was 
dilated about one inch. A French hook was placed on the 
anterior lip of the cervix and the handle held steady by the 
nurse. With two fingers of the left hand at the posterior lip 
of the cervix a large-sized bag was readily passed along the 
gloved hand in through the cervix by the aid of a curved 



THE HYDROSTATIC DILATING BAGS. 44I 

broad ligament clamp. It was then distended with sterile 
water, by using an eight-ounce metal syringe. As the bag was 
distended the handles of the broad ligament clamp sepa- 
rated and the clamp was then removed leaving the bag in 
utero. The tube was tied tightly with bobbin so there was 
no leakage. A sterile pad put over the vulva with a hole 
in its center for the tube to come through. At half-past ten 
the patient was out of ether and the pains were coming at 
intervals of five minutes, lasting three-quarters of a minute 
and were very severe. The fetal heart immediately after 
the insertion of the bag went to 160, but inside of twenty 
minutes settled down to 120 and remained there regularly. 
From eleven on she had obstetrical ether and with each pain 
the tube, protruding through the vulval pad, was gently 
pulled on. At half-past twelve the bag came out. Palpa- 
tion from above showed the head had descended materially 
and that the biparietal now was well down through the brim. 
At I A.M. pains were coming with intervals of a minute last- 
ing one and one-half minutes. Fetal heart was regular. Ma- 
ternal pulse had gone to 120. Uterus relaxed poorly be- 
tween pains and the lower segment was distinctly tender. 
I then decided to deliver her because of the relatively long 
labor which she had had, the rising pulse and the condi- 
tion of the uterus. She was etherized and then placed in 
lithotomy position. She was carefully scrubbed up. Per- 
ineum was thoroughly dilated so that the closed fist could 
readily be flexed out. Position was found to be O. D. A. 
The cervix was three-quarters dilated and very soft and thin. 
The posterior lip could just be felt but the anterior was 
found down between the head and the symphysis. 

The right blade was applied first and was readily placed, 
and then the left blade was placed opposite to the first. 
Rotating the handle of the left blade around the handle of 
the right the forceps readily locked. On the first tentative 
traction it was seen that it was the anterior lip that held the 
head from coming down. This was gradually pushed back 
by gentle pressure, and with very slight traction on the head 
downward. As the anterior lip retracted, the head slowly 
came down to the perineum and rotated fully to the arch. 



442 CASE HISTORIES IN OBSTETRICS. 

The perineum gradually stretched up. Circulation in the 
scalp was good and delivery was slowly finished. It was 
rather a difficult intermediate forceps. The baby cried at 
once. The application was poor. The left blade of the 
forceps was over the left eye. The right blade was over the 
right ear. When the cord stopped pulsating it was clamped 
and cut. There was a first degree median perineal tear. 
Placenta came away intact with all the membranes without 
any pressure whatsoever twenty-five minutes after the birth 
of the baby. Two deep catgut sutures of chromic No. 2 were 
placed about the base of the tear, bringing the deepest part 
of the tear into good approximation. Two silkworm -gut 
sutures were then passed so as to include the entire tear and 
then tied and left long. There was no bleeding, and the 
uterus acted well. She made a fair recovery from ether, 
vomiting two or three times. Pulse at delivery was 120. 
It steadily came down and remained of good volume. I left 
her at 4:30 with a pulse of 90. Uterus well contracted and 
no bleeding; in excellent condition. The baby weighed 
eight pounds, and was in excellent condition. 

June 6. She coughed much last night and was relieved 
by codeine sulphate gr. 1/4 repeated in one hour. Her tem- 
perature is normal, pulse 72. Lochia is sufficient, good color 
and no odor. No tenderness over the uterus. The breasts 
are large and pendulous. There is no milk in them. The 
baby moves its arms and legs well. The forceps mark over 
the eye is much better than yesterday. The edema is less 
and no secretion is present. 

June 10. Forceps mark has now practically cleared up. 
Milk has come in and the baby is nursing regularly. Tem- 
perature is normal and pulse varies from 68-78. The 
stitches which she complained of three days ago are now 
giving her no discomfort and there is no tenderness about 
the perineum. The external stitches look well. 

June 12. The uterus tcannot be felt above the symphysis. 
The lochia is very slight. The breasts are filling up between 
feedings and the baby is satisfied. Stitches were removed 
to-day and apparently a good result obtained. 

Patient made a good convalescence and began her exer- 



THE HYDROSTATIC DILATING BAGS. 443 

cises on the fourteenth day and kept them up, faithfully, un- 
til she got up on the twenty-first day. Vaginal examination 
in the fourth week showed no bulging on straining of either 
the anterior or posterior vaginal wall. Perineum well 
healed and a good result. Uterus normal in position and 
size and is freely movable. Cervix shows a slight stellate tear 
to be present, with a thick stringy bloody mucous plug pro- 
truding. A children's specialist is to have charge of the 
baby and the patient is discharged to her own family phy- 
sician in excellent condition. 

Summary of the Use of Hydrostatic Dilating Bags. 

The use of the hydrostatic dilating bag is not a new pro- 
cedure, but to Voorhees of New York is due its present 
popularity. There are other dilating bags on the market, 
but none is more satisfactory than this one of Voorhees. 
Voorhees in his original communication (Medical Record, 
Sept. 8, 1900) recommends the use of the small-sized bag 
first and when this comes out the insertion of the next larger 
size until dilatation is completed. The amount of manipu- 
lation that these procedures cause the patient, in my opinion, 
is unnecessary, and in my private and hospital work I never 
do it. If the indication for putting in a bag is clear then 
I prefer to etherize the patient and put in the iarge-size bag 
at once. In this way one is able to scrub out the vagina 
with 70% alcohol and place the bag in position, causing the 
patient a minimum amount of discomfort. 

The indications for the use of hydrostatic bags are many 
and varied. Many physicians can see no good in them, and 
they even go further and say they are the cause of sepsis, 
malpositions of the fetus and their use * ' meddlesome obstet- 
rics." I have used them either personally or ordered their 
use by my house officers very many times, and I have never 
regretted it. I regard their intelligent use one of the greatest 
advances in modern obstetrics. The above case is an ex- 
cellent example of their use. Given a case with ruptured 
or unruptured membranes and progress not being made, the 
introduction of a bag will materially help labor, in not a 
few cases the patients will deliver themselves shortly after 



444 CASE HISTORIES IN OBSTETRICS. 

the bag is expelled, and when operative interference is neces- 
sary the cervix is always soft and if not fully dilated the 
dilatation is very readily accomplished manually. 

Previous cases (Cases 27, 40, 49, 50, 51, 69 and 74), all 
show other conditions where the bags may be used. If 
the bag is inserted the physician must stay with the patient 
the entire time it is within the uterus. Careful watch of the 
fetal heart must be kept and the action of the uterus 
followed. 

The necessary instruments for the insertion of the bag are 
— the bag, a curved broad ligament clamp, a French hook 
(the vulsellum forcep tears out too readily), a hemostat, a 
pair of scissors, tape, an eight-ounce metal syringe, boiled 
water, a pair of gloves, a package of sponges and a sterile 
pad and gown. 

The technique of inserting the bag is as follows : The patient 
in labor has already been shaved, but if not in labor she 
must be shaved and an enema given before any attempt to 
insert the bag is made. The patient is put in moderate 
lithotomy position and the vulva carefully washed as in 
preparation for normal delivery (described on page 107). 
The operator fills the syringe full of boiled water, all air is 
expelled. The large-sized Voorhees bag holds eight ounces of 
water and that amount of water is put in after it is in place. 
If the physician uses other kinds or sizes he must find out 
how much the bag holds before he attempts to distend it 
within the uterus. If the patient is a multipara or a primi- 
para with cervix dilated about one inch, many times the 
vagina may be scrubbed out with alcohol, and the bag in- 
serted under a primary anesthesia, but if there is no dilata- 
tion complete anesthesia is necessary. The vagina is wiped 
out with alcohol, the French hook is then placed on the 
anterior lip of the cervix and its handle steadied by a nurse. 
The base of the bag is then pulled out and the bag rolled up 
from one side to the other as tightly as possible, and grasped 
firmly by the curved broad ligament clamp. It seems almost 
unnecessary to add that the bag is boiled before it is insert- 
ed into the uterus. Two fingers of the left hand are then 
passed into the vagina to the posterior lip of the cervix. 



THE HYDROSTATIC DILATING BAGS. 445 

With the right hand, the bag, held by the clamp, is passed 
in along the gloved left hand to the cervix and gently 
pushed through the os uteri. If resistance is met, the direc- 
tion of the clamp is slightly changed to a place where there 
is less resistance. 

The fingers in the vagina readily determine that the bulk 
of the bag is through the cervix. The clamp is then dropped 
by the right hand and steadied by the two fingers in the 
vagina. The metal syringe is now connected with the 
rubber tubing and the water is slowly forced into the bag. 
As the bag is distended the handles of the clamp are seen to 
separate and the clamp slips off the bag and is then removed. 
The bag is distended to its capacity. Before the fingers 
of the left hand are removed from the vagina the distended 
end of the bag is felt surrounded by the cervix. The tube 
is then tied with tape. To make sure that there is no leak- 
age the tube is bent on itself and again tied with the bobbin. 
A small hole is made in the sterile pad and the tube is brought 
through it and the pad put in place. The patient is put 
back to bed and allowed to come out of ether. 

If the bag is being used to induce labor gentle traction 
should be begun in about thirty minutes. From then on 
the tube should be pulled on with every contraction of the 
uterus, but if the contractions are of thirty minutes or more 
intervals, traction should be made in the interim every 
ten minutes. As the uterus begins to respond to this 
stimulus and contracts the traction becomes coincident with 
the contractions. If the traction is kept up while the uterus 
is contracting, not infrequently the pain caused is very severe 
and it is many times advisable to stop the traction after 
the uterus is contracting well. 

In cases where the delay is due to the non-dilating of the 
cervix, and the pains are good, it is not always necessary to 
exert any traction on the tube. Traction undoubtedly hurries 
the dilatation, but if dilatation is hurried too rapidly the 
relaxation of the cervix is not complete. 

To those physicians who never before have used the dilat- 
ing bags the change that takes place in the cervix after a 
bag has been in the uterus two to four hours is truly astonish- 



446 CASE HISTORIES IN OBSTETRICS. 

ing. From a rigid, tight, unyielding os to one which dilates 
merely by separating the fingers the change is astounding. 

Unfortunately the bag does not always work as satis- 
factorily as suggested, but in by far the large majority of 
cases this description of its use is not an exaggeration. The 
danger of sepsis must be recognized, and it is because of this 
danger that I do not like to insert bags unless the vagina 
has previously been scrubbed out with alcohol and it is 
hardly fair to the patient to do that without ether. 

In a very small number of cases the bag displaces the pre- 
senting part from the inlet so that a small part or cord 
prolapses. Unquestionably this is an objection to the use 
of the bag but it happens so infrequently that the good the 
bag does in the large majority of cases more than offsets the 
occasional complication which it produces. A physician 
who is not competent to deal with the complication should 
not place a bag in position. He should ask for a consulta- 
tion, and place on the consultant the responsibility for the 
outcome of the case. 

Intelligently used, the bag is a powerful help; carelessly 
used it causes damage and is therefore wrongly condemned. 



SECTION XXIV. 

RUPTURED UTERUS. 

Case 73. Incomplete Rupture of the Uterus. Patient 
is seen shortly after eleven in the evening of July 8th in 
answer to a telephone message from my house officer say- 
ing he was unable to deliver the shoulders in a case on 
which he had just attempted to do a low forceps. When I 
arrived at the patient's house he had succeeded in delivering 
the baby and was trying to resuscitate it. I found the fol- 
lowing conditions : — patient etherized, in the dorsal position 
across the bed. Patient's pulse was 120 and of fair quality. 
Uterus was well contracted and there was no external bleed- 
ing to note. Placenta was undelivered. While I scrubbed 
up for the delivery of the placenta the house officer gave me 
the following story: — It is the patient's tenth labor. No 
previous operative deliveries. At 8:30 the externe on the 
case had reported the patient to be in the second stage two 
and a half hours without progress. She was seen by the 
house officer at once and he found the patient having pains 
every three to five minutes lasting one minute. Uterus was 
not tender and was relaxing well. The baby was lying in a 
right position and was evidently very large. Fetal heart he 
found to be 152, a rise in rate from 130 in the past hour. 
Vaginal examination showed the head just within the vulva. 
Posterior lip of cervix not felt. Anterior lip found between 
the head and the symphysis. He advised operative delivery 
and it was accepted by the woman and her husband. Prep- 
arations were completed at once and the patient etherized. 
Position found to be O. D. A. Forceps readily applied, and 
the head delivered without difficulty. Traction followed on 
the head, but he was unable to start the anterior shoulder. 
After much traction without gain he telephoned to me for 
help. By the time I arrived he had succeeded in delivering 
the body. The baby breathed once or twice, but all attempts 

447 



448 CASE HISTORIES IN OBSTRETICS. 

to resuscitate it failed. In the light of the story of such a 
hard delivery, after delivery of the placenta I examined the 
patient by vagina. My right hand went up on the patient's 
right into a cavity which at first I took to be the relaxed 
uterus, and told the externe that he was not holding the 
uterus. He answered that he had his hand on the uterus 
in the patient's left side, and quickly showed by his manip- 
ulations that he was right. I then drew my hand out of 
this cavity the extent of which I did not attempt to deter- 
mine. I then examined the patient's left lateral cul-de-sac. 
This was intact as was the anterior and posterior. A hand 
was then gently passed through the os and in going up it 
was at once seen that there was a severe tear on the right 
side of the os uteri which communicated directly with this 
cavity on the right. The left side of the uterus was intact. 
No intestines were palpated. The diagnosis of incomplete 
rupture of the uterus was made. 

The surroundings were bad. I determined to bring the 
patient at once to the hospital for any further operative 
treatment that might be indicated. Several large clots of 
blood were removed from the broad ligament rent and there 
was also constant oozing of bright red blood. Because of 
this evident bleeding I packed lightly this cavity with sterile 
gauze, and then packed the uterine cavity. The patient 
was given ergot intramuscularly. She made a good recovery 
from ether, and her pulse when she was put back in bed 
was 132, of fair volume. The uterus was held firmly and 
pressure constantly applied over the packing on the right 
through the abdominal wall. The baby weighed eleven 
pounds and twelve ounces. As soon as the ambulance 
arrived the patient was taken to the hospital. 

On arrival at the hospital the patient was found to be in 
good condition. Pulse 128 and of good quality. Careful ex- 
amination of the abdomen showed the uterus to be well con- 
tracted at the level of the umbilicus, the smaller mass on 
the right had not increased in size from the time it was 
palpated at the patient's home. By percussion of the flanks 
no free fluid found. She was breathing easily and looked 
in good condition. There was no staining through of the 



RUPTURED UTERUS. 449 

packing. I then determined to leave her alone. She was 
at once put in Fowler's position. No stimulation ordered. 

July 9. Temperature this morning 100°, pulse 104. 
Patient apparently in excellent condition. Uterus tender. 
No tenderness in the left lower quadrant. Exquisite tender- 
ness and muscular spasm in the right lower quadrant. She 
was let down from Fowler's position, and placed in the dor- 
sal position across the bed with shoulders elevated. The 
packing was then slowly and gently removed without ether. 
I did not give her an intra-uterine douche as I was fearful 
of where the wash water might flow. The packing was 
entirely soaked through, but no apparent fresh bleeding 
followed the removal of the gauze. She was again put into 
Fowler's position with ice-bags over the lower abdomen. In 
the afternoon she voided urine involuntarily. Examination 
of the abdomen then showed a resilient tumor in the left 
lower abdomen, dull on percussion. She was catheterized 
and thirteen ounces of normal colored urine withdrawn. She 
was now ordered hexamethylenamine gr. v. t. i. d. Tem- 
perature tonight normal and pulse 96. Lochia normal in 
amount and character. 

July 10. Temperature 98°, pulse 92. Uterus well con- 
tracted and less tender; tenderness marked on the right 
with slight muscular spasm. An enema this morning ob- 
tained a fair result. Lochia is strong, but not foul. Normal 
in amount. 

At noon the patient complained of very severe sharp pain 
in the right lower quadrant. Examination showed that the 
spasm had greatly increased. The castor oil which she had 
in the morning gave several large results. Afternoon tem- 
perature 100.4°, pulse 94. The patient is taking soft solids 
well and is not vomiting. 

July II. Temperature and pulse the same. Tenderness 
and spasm on the right less. Uterus is involuting slowly and 
is not tender. 

July 12. Temperature this morning 101°. Pulse 100. 
Breasts are filling and are quite uncomfortable. Support- 
ing binder with ice-bags applied to both breasts. There is 
no material change in the abdominal condition. 



450 CASE HISTORIES IN OBSTETRICS. 

July 14. This morning temperature 101°, pulse 92. 
Yesterday I put a bivalve speculum in the vagina to see the 
condition of the cervix and the tear in the broad ligament. 
The cervix is clean and red lochia is coming from it. From 
the tear is coming a small amount of dirty, dark, foul smell- 
ing discharge. Culture was taken from it and the report 
to-day received was ''practically a pure culture of strepto- 
coccus." It is evident the cavity is draining and with a 
dropping pulse I decided to leave it severely alone in order 
to allow it to become well walled off from the abdominal 
cavity. 

July 16. Definite resistance to palpation is readily felt 
in the right lower pelvis. Temperature this morning 103°. 
Pulse 100, but of poor quality. Patient this morning com- 
plains of a very severe headache and looks septic. The 
lochia was foul and much less in amount to-day. Bivalve 
was passed again into the vagina and it was seen that the 
opening of the tear had closed down in size a great deal. 
The patient was then given ether, and the finger passed into 
the cavity and the opening dilated carefully. At once much 
foul smelling greenish colored pus escaped. The cavity was 
then washed out carefully with a weak solution of chlorinated 
soda. Care was taken to keep the top of the douche can 
but a foot above the level of the bed so that there could be 
no force to the stream. Sterile gauze wick soaked in alco- 
hol then packed gently into the cavity. 

January 17. Temperature at 9 a.m. was 104.2°, pulse 
106. Patient vomited this morning once. Abdomen is not 
distended and the tenderness over the right side is much 
diminished. Uterus is not tender and is involuting slowly. 
Profuse foul discharge present all day yesterday and last 
night. Wick removed to-day. No backing up of pus. 
Cavity washed out as before. Bowels are freely open. 

July 18. Temperature this morning 102.2°, pulse 96. She 
looks much brighter. Has not vomited since yesterday, and 
has taken her nourishment of soft solids well. Cavity again 
washed out and much pus came away in the wash water. 
The tenderness on the right is much less and the induration 
less marked. Ice-bag now omitted. 



RUPTURED UTERUS. 451 

July 19. Temperature is steadily dropping. Pulse is 
slowly coming down and is of much better character. Lochia 
now is much less foul but is profuse and of a whitish color. 
Cavity is washed out now twice a day. It is rapidly shut- 
ting down. 

July 23. Patient three days ago was let down from 
Fowler's position. To-day she sat up in bed with a head 
rest. Temperature is normal and pulse 80. She is eating 
the regular house diet, and is gaining rapidly. 

July 29. Patient is now up and about the ward. By 
abdominal palpation there is no tenderness or induration 
present. Irrigations of the cavity stopped as it now has al- 
most completely closed. Hot vaginal douches of sterile 
water twice a day now begun. 

August I. Vaginal examination shows the uterus well in- 
voluted, normal position, but not freely movable. Appre- 
ciable thickening where the tear was, but no tenderness. 
Definite scar is felt running off from the cervix to the right 
pelvis. Cervix has a deep bilateral tear present. Sinus is 
closed. Patient is discharged. 

Summary of Ruptured Uterus. 

Text books generally state that a rupture of the uterus is 
an uncommon accident in obstetrics. That it is a commonly 
recognized accident is rare, that it is an admitted accident 
is very rare. If autopsies followed in all deaths that oc- 
curred in obstetrics, especially in those cases where difficult 
operative work has been done, the primary cause of death I 
am confident would be found to be a rupture of the uterus 
much oftener than it is recorded. 

Two types of rupture of the uterus are recognized. First, 
the complete, in which the tear extends through the muscu- 
lar layer and peritoneal coat and the peritoneal cavity is 
opened. Second, the incomplete in which the peritoneal 
coat of the uterus remains intact. Case "^2 is a good ex- 
ample of this latter type. The usual primary cause for the 
rupture is an unrecognized disproportion bet^veen the fetus 
and the pelvis. Operative deliveries in neglected cases, for- 
cible dilatation in placenta praevia or in eclampsia may be 



452 CASE HISTORIES IN OBSTETRICS. 

frequent causes of rupture. Careless, ill timed, and badly 
fashioned operating by poorly trained physicians cause many 
ruptured uteri and the true condition is covered up by the 
terms post-partum hemorrhage and pulmonary embolus. 

The immediate cause of the rupture in this case was the 
excessive size of the child. What the condition of the vaults 
of the vagina were in this patient as the result of previous 
deliveries was unknown. There may have been well-marked 
cicatrices present and when the operator accomplished the 
delivery of the shoulders the cicatrix ruptured. When scar 
tissue starts to tear no one can tell where it will stop. That 
scar tissue may be present in the vaginal vaults, even when 
no operative delivery has occurred, all physicians who have 
had experience in gynecological clinics recognize. Scar 
tissue many times will soften and dilate, but its action al- 
ways is problematical, and a source of worry. Should this 
patient ever again become pregnant, a Csesarean section 
would without doubt be the conservative method of delivery. 

The signs of a threatening rupture of the uterus are suf- 
ficiently well marked for any physician of average intelligence 
to appreciate. The contractions of the uterus become con- 
stant. There is no relaxation, the uterus is in a state of 
tetanic contraction. Palpation of the uterus causes ex- 
quisite pain. Not infrequently the moment the hands are 
placed on the uterus the patient will at once try to lift them 
off. The contraction ring may be palpated, even seen. 
The higher this ring is found the greater the danger of rup- 
ture occurring. The patient's pulse is accelerated and the 
temperature is often elevated. These signs may not all be 
present, but when they are, and the more marked they are, 
the more imminent is the rupture. 

When spontaneous complete rupture takes place the 
patient is seized with a sudden, sharp, intense pain ; then fol- 
lows at once a quiescent stage. The uterus stops contract- 
ing, the patient goes at once into more or less profound 
shock. The pulse if rapid before, becomes more rapid, of 
poor volume and tension. The signs of hemorrhage then 
rapidly follow, the hemorrhage may be either internal or ex- 
ternal or combined. The change in the contour of the 



RUPTURED UTERUS. 453 

uterine tumor depends upon how completely the fetus 
escapes into the abdominal cavity. The history of previous 
tumultuous labor, its sudden cessation accompanied by shock 
make the diagnosis of rupture of the uterus not difficult. 
In the treatment of this condition prevention is most im- 
portant. Prevention means careful intelligent oversight of 
the patient during the pregnancy as well as during the 
labor. 

A patient who has had one Caesarean section if she is al- 
lowed to go into active labor at a future pregnancy may 
rupture her uterus at the scar, and for that reason she must 
be very carefully watched for signs of threatening rupture. 
Once a patient has had a Caesarean section the conservative 
procedure is the repetition of that operation. We all have 
seen Caesarean patients deliver themselves without disaster in 
a subsequent labor. Because one patient has done this is no 
argument that all patients who have had Caesarean sections 
should be allowed to go into labor. 

I have already said that poor operative work is a frequent 
cause of rupture, and in order to prevent this the entire 
standard of obstetric work throughout the country must be 
raised and physicians must realize that they must not operate 
unless they have received adequate training. 

The treatment of a ruptured uterus varies according to 
whether the rupture is incomplete or complete, whether there 
is active hemorrhage or whether there is no hemorrhage. In 
cases where the rupture is complete and the baby undelivered, 
laparotomy unquestionably must be done. The fetus is 
practically always in the abdominal cavity and no attempt 
should be made to deliver it through the rent by vagina. 
The fetus and placenta removed through the abdominal in- 
cision, the question then of repair of the rupture or of hys- 
terectomy comes up. If sepsis is absent and the rent is 
where it may be successfully closed, this may be done but 
the probability of sepsis is so great that in all but the rare 
case hysterectomy is the operation of election. 

In an incomplete rupture the decision for performing a 
laparotomy is determined by the presence of hemorrhage and 
the patient's condition. The recorded case is a good ex- 



454 CASE HISTORIES IN OBSTETRICS. 

ample of the management of an incomplete rupture of the 
uterus. If the patient survives the first shock the danger 
is sepsis. Sepsis was here present, but was not virulent, and 
the patient gradually overcame it and left the hospital in 
excellent condition. 



SECTION XXV. 
HYDRAMNIOS. 

Case 74. Acute Hydramnios. Patient presents herself 
at the office on November 20th, having been referred by her 
family physician. She says her last menstruation, which 
was normal in all respects, began on May 22. She, there- 
fore, will be due for delivery about the first of next March. 
She is thirty-one years old, and has never been ill. 

The present pregnancy is her third, the first two preg- 
nancies terminating in normal easy deliveries and the chil- 
dren weighed nine pounds, and nine pounds twelve ounces. 
The last baby was born fifteen months ago. After the last 
baby she developed on the eighteenth day an inflammation 
of the left breast and six days later an abscess was opened. 
In the course of a month she says the incision healed. 

Her present pregnancy is not remarkable. She apparently 
is in excellent condition. Palpation of the abdomen to-day 
shows the uterus to be at the level of the umbilicus. Defi- 
nite fetal motion is felt on the patient's right. Left breast 
shows an inch incision in the outer lower quadrant. Blood 
pressure 112 mm. of Hg. Specimen of urine passed in the 
office was clear, of normal color, acid in reaction, specific 
gravity 1.020. No albumin or sugar present. I went over 
with her carefully the care that she should take of herself 
during this pregnancy. 

December 5. She reports to-day at the office saying that 
three days ago she waked up with a terrible headache over 
her forehead, but that gradually during the morning it grew 
better. Trying to explain to herself the reason for this 
headache she says she began to realize that she was drinking 
but one or two glasses of fluid during the day, and that her 
bowels had not moved for two days previous to the begin- 
ning of the headache. She at once took an enema and ob- 
tained a good result. She then began to drink water freely. 

455 



456 CASE HISTORIES IN OBSTETRICS. 

Since her bowels moved well and she began drinking six to 
eight glasses of water each day, there has been no return of 
the headache. Blood pressure to-day was Ii8. Urine 
which she brought to the office from the twenty-four hour 
amount, which was a little over three pints, was of normal 
analysis. 

January 2. Is in excellent condition in every respect. 
Blood pressure ii8. 

January ii. Comes in to the office to-day saying she has 
had more or less headache for the past two days, and she 
noticed that the urine was darker in color than it previously 
had been. She is again very constipated, her bowels not 
having moved for two* days. Last night she had a ** severe 
burning sensation in the pit of her stomach." She has had 
no flashes before her eyes. Her blood pressure is ii8. She 
has no edema of face or hands. Analysis of urine brought 
in was : — Color high. Specific gravity i .028. Albumin very 
slight trace. Sugar absent. Sediment showed a very rare 
hyaline cast, few small round cells, occasional leucocyte and 
much vaginal detritus. 

She was sent home. Told to take a hot bath and at 
once to go to bed and to cover herself up with blankets. 
She is to take a teaspoonful of Epsom salts every half hour 
for four doses. I limited her diet to milk only and water. 

Her husband telephoned to-night that his wife had no 
headache, was sweating profusely and that her bowels had 
moved freely three times. 

January 12. Saw her to-day at her own home. She has 
no headache, and wants very much to get up. Bowels have 
moved twice this morning. Her skin is moist. Palpation 
shows fundus a little more than half way between the um- 
bilicus and the ensiform. Fetal motion felt and seen on the 
right. A question if the baby is not presenting at the present 
time by the breech. Blood pressure is 108. Examination 
of the urine shows no^bumin to be present by the nitric 
acid test. (Nitric acid was carried out to her home that the 
urine might be tested at once.) Toast and cereals are 
added to her diet.. She was asked to take two teaspoonfuls 
of Epsom salts each morning. A hot bath was ordered each 



HYDRAMNIOS. 457 

night. If she continues to feel as well to-morrow as to-day 
she is to get up, but is to stay on one floor. 

January 14. Urine: — Amount just under three pints. 
Color high. Reaction acid. Specific gravity 1.020. Al- 
bumin very slight trace. Sediment as above recorded. She 
has no untoward symptoms. 

January 17. Telephones to-day that except for a slight 
pain in her right side at her ribs she is very comfortable. 
She now is on a soft solid diet. Bowels are moving well, and 
the urine varies in amount from three to four pints, exami- 
nation of which shows no difference from that previously 
noted. 

January 18. Telephones late this morning that she had 
difficulty late yesterday afternoon in passing her water, but 
after taking a hot bath she voided without difficulty. She 
is complaining of difficulty in breathing, that the slightest 
exertion makes her breathe rapidly, and that the pain in her 
right side is distinctly worse. 

I saw her in the afternoon. She looks drawn and pinched, 
with dark rings under her eyes. Color which she had^at 
the last visit is gone. She is in bed propped up on three 
pillows. She complains of the pain, more or less constant in 
her right side and difficulty in breathing. Her difficulty in 
breathing she attributes to her size from the pregnancy. 
She has no headache. Her temperature is 98.4°, pulse 112, 
respirations 28, Blood pressure is 120. 

Physical Examination: — Heart sounds normal. Ex- 
amination of both lungs normal front and back. Abdomen 
is globular and the skin is shiny with minute dilated blood 
vessels present throughout the entire abdomen. Abdomen 
is tense and there is no pitting on pressure. No fetus is 
palpated. No fetal motion felt. No fetal heart heard. En- 
tire abdomen except on the right and left flank and across 
the epigastrium is dull on percussion. Fluid wave is readily 
obtained. There is no edema of the vulva. Slight edema 
of the ankles and of the legs half way up to the patella. 
Measurement of the abdomen at the umbilicus is forty- three 
inches. 

Diagnosis of acute hydramnios is evident. I advised her 



458 CASE HISTORIES IN OBSTETRICS. 

to come in town to a hospital at once where she could be 
properly looked after. Both she and her husband readily 
accepted the advice. 

January 19. Last night after she was made comfortable 
in the hospital she slept she says better than for a week 
past. Pulse this morning "^d, temperature normal, respira- 
tions 24. She has had no contractions. This morning I 
had to go to another patient some distance out of town and 
while absent she started having pains every two minutes. 
Another physician, whom I had left in charge, was called but 
in the course of an hour all pains ceased, and he determined 
to await my return. I saw her in the early evening, and as 
there were no signs of labor I decided to wait a few hours 
more hoping the uterus would start to contract before 
rupturing the membranes. 

January 20. No sign of labor to-day. She is very com- 
fortable, and as her pulse was still 76 and her general con- 
dition much better than on entrance to the hospital I 
decided to wait until contractions began or at least another 
twenty-four hours. 

11:45 P.M. Telephone message from the hospital that the 
patient had just begun having pains, and for the last twenty 
minutes had had them every five minutes. She was having 
no show the nurse said but the pains hurt her a great deal. 
I went at once to the hospital and found the patient having 
pains every five minutes, lasting from one-half to three- 
quarters of a minute. Pulse had risen to 90. During a pain 
the pulse rose to 100. Uterus was contracting well. Relaxed 
somewhat between pains, but because of the amount of dis- 
tension that was present complete relaxation was impossible. 

Now that the uterus was contracting I determined to 
rupture the membranes with the aid of a catheter and a 
stylet in order to let out some of the liquor, and then to put 
in a large-sized Voorhees dilating bag to make certain that 
the uterus would not stop contracting when the liquor was 
drained off. She was etherized and then prepared in the 
usual manner. The perineum was dilated very quickly and 
without any difficulty. The anterior lip of the cervix seized 
with a double hook and steadied by a nurse. Left hand 



HYDRAMNIOS. 459 

passed into the vagina and a web catheter with the stylet 
in it was pushed in through the external os, which was dilated 
two fingers, into the uterus. The stylet was so bent that 
when it was withdrawn a little way the end protruded 
from the eye in the catheter. The catheter was then rotated 
slightly so that the stylet punctured the membranes. 
The scheme worked satisfactorily and liquor immediately 
came out. I withdrew the stylet entirely. The catheter 
must have gone into the amniotic cavity for the only liquor 
that came^out was through the catheter. The amniotic sac 
was slowly emptied and the contractions still continued. Pal- 
pation by my assistant showed that even with the amount I 
had let out there still was considerable waters present in the 
uterus. The uterus now relaxed satisfactorily and when a 
pain came contracted well. After I had let out possibly 
three or four quarts of fluid I withdrew the catheter and put 
in the large bag and immediately distended it with water. 
A sterile pad was put over the vulva and the patient put 
back to bed. She immediately came out of ether. Pains 
continued coming in decreasing intervals of five, three or 
two minute lasting from one-half to one and a half minutes. 
The uterus relaxed well between pains. The bag was put in 
at one a.m. January 21st. At each pain the nurse pulled 
gently on the bag. 

At half past five the bag was found to have come through 
the cervix and a few minutes later it came out over the 
perineum. I at once decided to etherize and deliver her for 
her pulse had risen to 120; the uterus was not relaxing as well 
as earlier, and the lower uterine segment was slightly tender. 
Patient was again etherized and prepared. Four ounces of 
high-colored urine withdrawn by catheter. Examination of 
the cervix showed that it was fully dilatable and thin. 
Examination of the presenting part gave a soft mass. It is 
difficult to feel any bones. Question what the presentation 
was at this first examination. On pushing the hand further 
into the uterus the definite irregularities of the face were 
felt on the patient's right. The entire head felt edematous. 
The position was made out to be occiput left anterior and 
the forceps were then applied. Traction brought down the 



460 CASE HISTORIES IN OBSTETRICS. 

head at once to the perineum and the head then held. With- 
out traction-rods I could not sink the occiput beneath the 
symphysis. Traction-rods were then used and after much 
traction the head was gradually brought low enough to be de- 
livered with much difficulty. Just as the ,head was crown- 
ing it was seen that there was an area of maceration at the 
occiput. The soft feeling of the head was due to the edema 
which was present. The head delivered, traction downward 
on the neck gained absolutely nothing. Then with steady 
traction downward on the neck and with the blunt hook in 
the anterior axilla I drew down the anterior shoulder and 
was able to deliver it from beneath the symphysis. The 
blunt hook was then put into the posterior axilla and with 
traction first downwards and then slightly upwards the 
posterior shoulder was delivered. Head and shoulders de- 
livered, there was as much difficulty in delivering the body 
as there had been with the shoulders because of the great 
amount of edema that the baby presented. After much 
traction the body was delivered. It was then seen that the 
arms, legs and abdominal wall pitted very readily when 
pressed upon. The abdomen was distended to about twice 
the size of a normal full-term baby and there were marked 
areas of maceration over the abdomen and other areas of 
maceration over the back. The whole body presented a 
condition of general anasarca. The cord was small, not 
edematous. No knots present in it. It was clamped and 
cut, and the baby was put aside. Examination of the 
perineum showed that no fresh tear of the perineum was 
present. Part of the placenta was protruding from the 
vagina. The uterus continued to contract well. There was 
no bleeding. Maternal pulse at this time 148. Coincident 
with the third contraction the placenta came away. It was 
very large, nearly twice the normal size and very edematous, 
and friable. Membranes came away intact. As far as could 
be determined the placenta was also intact. Ergot was given 
intramuscularly. Because of the hard delivery and the 
number of times that the hand was thrust into the vagina I 
gave an intra-uterine douche of salt solution followed by 70% 
alcohol. Examination of the cervix showed a slight right- 



HYDRAMNIOS. 461 

sided tear and on the left a deeper laceration, but there 
was no bleeding. The uterus was intact. The patient 
was put back to bed in fair condition. Uterus was held 
constantly for an hour. It stayed well contracted. Grad- 
ually the pulse came down and her condition steadily im- 
proved. At eight o'clock her pulse was 100. The baby was 
a boy and weighed eight pounds and five ounces and was 
about five weeks premature. 

January 22. Temperature normal. Pulse 80. Uterus 
hard. Well contracted. Not tender. Lochia normal in 
amount and character. Anus very edematous and tender. 
She is taking her food well and there are no untoward symp- 
toms. She is beginning to be shghtly distended. Late this 
afternoon she was given three-quarters of an ounce of castor 
oil, and two hours later given an enema, and an excellent 
result was obtained. 

January 23. Slept well last night. No distension present. 
For the edema about the anus pads of absorbent cotton 
soaked in equal parts of hamamelis and water have been 
applied every two hours. Lochia is normal in amount and 
character. Uterus is involuting well and is hard and well 
contracted. Temperature is 98.8° and pulse 80 to-night. 

January 25. Breasts began filling up to-day and the patient 
is quite uncomfortable. Temperature at nine is 99° and pulse 
90. Left breast in which she had an abscess her last preg- 
nancy is much more tender than the right. Ice on both 
breasts and a light supporting binder. Is in excellent con- 
dition. 

February 4. Has done well. Lochia now very slight. 
Absolutely no tenderness any\vhere in the pelvis. Breasts 
which were uncomfortable for twenty-four hours after the last 
note have been left absolutely alone. She is doing her ex- 
ercises regularly morning and night, she is very anxious to 
go home. 

February 5. For family reasons she is going home to- 
morrow. Vaginal examination to-day shows practically no 
discharge. The old tear of the perineum is evident. No 
bulging of the anterior or posterior wall. Uterus is in normal 
position and within normal limits of size. Nothing felt on 



462 CASE HISTORIES IN OBSTETRICS. 

the sides. Speculum shows slight bilateral tear of the cervix. 
More marked on her left. ! 

March 20. Patient reports to-day at the ofhce. She is in 
excellent condition. Vaginal examination reveals nothing 
abnormal. Pathological examination of the fetus and the 
placenta gave no cause for the condition found. 

Summary of the Management of Cases Presenting 
Hydramnios. 

The above case brings up the management of a patient 
who develops hydramnios, acute or chronic, in the course of 
her pregnancy. The management of either condition is 
essentially the same. 

Hydramnios is not of itself a disease, but a sign of a con- 
dition which may have different underlying causes. There 
is no one condition which can be said to be the cause of 
hydramnios. On the part of the mother syphilis, cardiac 
and renal disease are given as possible causes. Whether 
syphilis is the direct cause or because of its effect on the 
fetus is not definitely known. On the part of the fetus, mal- 
formations, abnormalities of the placenta or membranes and 
multiple pregnancies are supposed causes. What is cause 
and what is effect, however, is not known. No one explana- 
tion is as yet satisfactory for all cases and in many cases no 
satisfactory answer can be given. In this case no explana- 
tion of the condition was found, for examination of the fetus 
and placenta showed no pathological condition, except the 
edema and the mother had no demonstrable disease. Syph- 
ilis has not been ruled out as yet by the Wasserman re- 
action and before this patient becomes pregnant again it 
must be. 

The symptoms arising from both acute and chronic hy- 
dramnios are practically all due to pressure on the various 
organs. In an acute case the body bears this sudden in- 
creased pressure poorly with the result that the discomfort 
to the patient may be very great. The above recorded case 
is an excellent example of the acute type of this condition, 
and to those who have never seen it, the acuteness of the 



HYDRAMNIOS. 463 

onset is almost unbelievable. In the chronic form where the 
accumulation of the amniotic fluid is relatively slow the 
various organs adjust themselves to this increased pressure 
and the discomfort, though marked, is seldom so great as in 
the acute form. 

The diagnosis of this condition is very easy provided the 
diagnosis of pregnancy is well established before this com- 
plication arises. In the above case the pregnancy was known 
to exist and with the physical examination as recorded on 
January i8th no other diagnosis than that of acute hydram- 
nios was possible. Had a vaginal examination been made at 
this time ballotment in all probability would have been 
obtained, but in this individual case vaginal examination 
was not indicated. It was contra-indicated because at that 
time, at her home there were no preparations for delivery, 
and one vaginal examination might have ruptured the mem- 
branes. If the diagnosis of pregnancy had not previously 
been established, a vaginal examination should have been 
made. Once the diagnosis of pregnancy established there 
is practically no other condition with which hydramnios may 
be confounded. 

In cases where the diagnosis of pregnancy has not been 
established the diagnosis of hydramnios may be very difficult. 
As happened in this case, no fetal parts were felt and no 
fetal heart was heard and when those two important signs 
of pregnancy are absent, the diagnosis of hydrammios becomes 
difficult. Hydramnios is often associated with multiple 
pregnancy and usually is not of marked degree. 

The treatment of hydramnios depends upon the grade that 
is present. If slight, no special treatment is necessary except 
that care must be taken when the membranes rupture to be 
sure that the cord does not prolapse. 

In acute hydramnios delivery is necessary on account of 
the pressure symptoms which arise. In a very large per- 
centage of cases where marked degrees of hydramnios are 
present malformations of one kind or another appear in 
the fetus. Because of this fact the life of the child is of 
secondary consideration (unless the patient is a Catholic) 
and the welfare of the mother alone need be considered. 



464 CASE HISTORIES IN OBSTETRICS. 

If the membranes rupture low down with a sudden escape 
of the amniotic fluid, prolapse of the cord or small parts with 
resulting malpositions of the fetus may follow, but the 
mother must not be subjected to the added risk of a forced, 
hard operative delivery for the sake of a baby which in all 
probability is abnormal. 

The danger to the mother in this sudden emptying of the 
uterus of the amniotic fluid is the separation of the placenta 
and its resultant hemorrhage. 

High rupture of the membranes with gradual draining off 
of the fluid is the best way to treat cases of hydramnios of 
severe grades. After the waters are drained off, labor may 
start up at once or, as is more apt to be the case, many hours 
may elapse. This is especially so when the distension is great. 
To obviate this delay a dilating bag may be introduced into 
the uterus. This was done in this case and labor progressed 
steadily. 

Given a case of moderate degree of hydramnios there is 
necessarily no indication to interfere with the pregnancy or 
labor unless the signs of pressure become severe. When 
labor starts it may be inefficient because of the over-dis- 
tention of the uterus. If the labor is unsatisfactory, high 
rupture of the membranes should be done. Labor will then 
probably progress to a satisfactory termination. The means 
to meet a post-partum hemorrhage must be at hand. In 
cases of acute hydramnios the sooner the uterus is emptied 
the better. The question may be raised why the above 
patient was allowed to wait forty-eight hours after the diag- 
nosis was made before interference was begun. My plan 
was to watch her a few hours closely and on the first sign of 
contractions of the uterus to rupture the membranes, feeling 
that if contractions were present the danger of serious post- 
partum hemorrhage would be much lessened. Had I been 
present on the 19th of January when contractions began, 
unquestionably I would have ruptured the membranes. On 
my return the patient was resting quietly and in excellent 
condition and I therefore determined to wait. Had this 
patient not been under hospital supervision, that is, had she 
refused to come to the hospital and insisted upon staying in 



HYDRAMNIOS. 465 

her home, she should have had labor induced at once for 
the danger of uncontrollable post-partum hemorrhage I be- 
lieve would have been less than the danger which sudden rup- 
ture of the membranes entailed, without competent medical 
care at hand. The outcome of this case is an argument in 
favor of the judgment used. This case points out a further 
lesson that in each and every obstetric case individual study 
is necessary and a mode of procedure should be mapped out 
which in all probability will give a successful result. 



SECTION XXVI. 

CICATRIX IN THE VAGINA COMPLICATING 

LABOR. 

Case 75. MuLTiPAROUs Labor. Cicatrix in the Va- 
gina. Manual Dilatation. High Forceps. Patient is 
seen for the first time September 15th. She is a Jewess in 
labor at term in her fourth pregnancy. Her first baby was 
delivered normally after a long labor, but the baby was 
stillborn. The second also was a long labor, without oper- 
ation, and the baby was stillborn. The third baby is living. 
All these babies were born in Russia, and no intelligent 
history of what happened there is obtainable. 

Labor is said to have begun at 11 p.m. September 14th. 
The membranes ruptured at 2 p.m. September 13th. I saw 
her at i p.m. September 15th, because of lack of progress 
in a multipara and because of incomplete dilatation. Palpa- 
tion showed a large, fat woman in active labor. Pains were 
coming every two minutes and lasting one and a half minutes. 
Uterus was not tender. Vaginal examination revealed a 
cicatricial band in the vagina completely surrounding the 
vault which admitted two fingers, and an inch beyond was 
felt the cervix, the amount of dilatation of the cervix was not 
determined. The head was not engaged. Fetal heart was 
160, heard in the left lower quadrant. Patient's pulse 112 
and her temperature 101°. I advised that she be sent at 
once into the hospital for delivery. After some delay this 
advice was accepted by the family and she arrived at the 
hospital at quarter past two. She was immediately prepared 
for operation. She was etherized, placed in lithotomy 
position, catheterized and the vagina dilated. It was then 
seen that the band had thinned out to a superficial band of 
tissue which ruptured on dilating. Beyond this ruptured 
band the cervix was found two- thirds dilated. Dilatation of 
the cervix was completed manually. Position of the baby 

467 



468 CASE HISTORIES IN OBSTETRICS. 

found to be O. L. A. and forceps were applied. Forceps 
readily locked and the head was brought down with axis- 
traction to the perineum, and then readily delivered. There 
was no fresh tear of the perineum. Baby was readily re- 
suscitated. Placenta was expressed without bleeding, and 
ergot was given intramuscularly. The tear of the vagina 
from dilating required no repair as it involved only the 
mucous membrane. Patient made a normal convalescence and 
nursed the baby. On September 28th vaginal examination 
showed a deep bilateral cervical tear. Uterus had involuted 
normally and was in normal position. The cicatricial band 
had so contracted at this time that it admitted but two fingers. 
The patient was discharged well as was the baby and she was 
warned if she ever became pregnant again to place herself 
under the charge of the hospital so that the progress of her 
pregnancy could be watched. 

Nineteen months later my house officer reported to me at 
five one afternoon the following facts: 

That he had seen at eleven p.m. the night before a multi- 
para who had been in labor twenty-four hours ; that she was 
in good condition, uterus soft and not tender, and that he 
had watched her for nearly an hour during which time she had 
had no contractions; that he then gave her a quarter of a 
grain of morphia in the hope that she would obtain sleep and 
then start up in good labor; that this morning the externe 
reported that she was in labor, and pains were coming every 
five minutes; that at three- thirty p.m. he had seen her again 
and found the following conditions : Large, pendulous abdo- 
men, position of fetus O. L. A. No fetal heart heard. Uterus 
relaxing poorly between pains and slightly tender. Patient's 
pulse 120. Vaginal examination gave a mass of scar tissue 
in the vaults, os uteri dilated one finger, biparietal not 
through the brim. 

I saw her at once and confirmed his findings. Vaginal ex- 
amination by me showed the vault was a mass of scar tissue 
with several radiating bands easily palpated. Os uteri 
admits one finger and a soft mass is felt beyond, which is, in 
all probability, a caput succedaneum. At this time I re- 
marked to the house officer that this condition was very 



CICATRIX IN THE VAGINA COMPLICATING LABOR. 469 

much like one I had operated on some months before when 
labor had been delayed by a cicatrix in the vagina. Her 
temperature was taken while I was there, and found to be 
100°. I advised her removal at once to the hospital for de- 
livery, and she accepted my advice. 

As soon as she entered the hospital she was prepared for 
operative delivery. She was etherized and placed in lithot- 
omy position. The usual preparations were carried out. 
Vaginal examination showed the os uteri dilated one finger. 
Gradually the cervix was divulsed. It was accomplished 
slowly and without undue laceration. Dilatation completed, 
and as the position of the fetus was being verified a moder- 
ately tight contraction ring was felt and also a pulseless 
loop of cord palpated beside the head. Forceps readily ap- 
plied to a high O. L. A. and with slow, careful traction the 
head gradually descended, and was delivered without diffi- 
culty. The baby was dead, and over an area of about the 
diameter of an inch, just at the umbilicus, the skin was 
slightly macerated. Placenta later came away intact with 
all the membranes. There was no excessive bleeding. 
French hooks placed on the anterior and posterior lips of 
the cervix and the cervix was drawn down. The tears in 
the cervix were irregular, but not excessively deep and as 
there was no bleeding no attempt to repair the cervix was 
made. An internal tear of the perineum was repaired at 
once with two chromic catgut sutures. A hot intra-uterine 
douche of salt solution was given, and it came back clear. 
This was followed by one pint of 70% alcohol. Patient was 
put back to bed with a pulse of 130, but of good volume. 
Uterus acted well and there was no bleeding. Gradually 
her pulse dropped in rate. 

She made an uneventful convalescence. Her breasts gave 
her no discomfort, and dried up very quickly. She got out 
of bed on the twelfth day. On the next day vaginal exami- 
nation gave the following result : — General bulging of the 
anterior and posterior vaginal wall. Old lacerations of the 
perineum. There is a tear on the left vaginal wall reaching 
to the vault. On the right there is a cicatricial band run- 
ning from the cervix across the vault. The cervix has a 



470 CASE HISTORIES IN OBSTETRICS. 

stellate tear. The vault is so contracted that it admits but 
two fingers. The uterus is in normal position, fairly well 
involuted, not freely movable. There is no flowing present. 
Two days later she was discharged from the hospital. 



Investigation showed that these two cases were succeeding 
pregnancies in the same woman. Several interesting problems 
are brought up by these pregnancies. The patient was un- 
intelligent, and a satisfactory history of her previous labors 
was not obtained, but it is fairly certain that no instru- 
ments were used in the delivery of the three previous children. 
Many surmises as to the cause of the vaginal cicatrix are 
possible. The important point here was that we had a 
multipara in good labor who did not make progress. The 
reason for lack of progress must always be determined. 
This necessity was appreciated the first time we had charge 
of this patient, but the second time the house officer mis- 
interpreted his findings. He for some reason disregarded the 
history of the patient's twenty-four hours of labor, and gave 
her morphia so she might obtain sleep. When he examined 
her thirty-six hours, at least, after labor began, he found 
the cause of the delay — namely the scar tissue, and then at 
once reported his findings to me. 

The history of previous operative deliveries is always im- 
portant, and must be obtained. Had this house officer ob- 
tained this history and the fact that the patient was the 
same as the one we previously had looked after, in all prob- 
ability, the baby in the last pregnancy would not have died. 
With an unintelligent patient it is not sufficient to warn her 
as we did the first time, to come to the hospital early, that 
she may obtain the best of treatment. Such patients must be 
followed up, and the most satisfactory way yet found is to 
have a pregnancy clinic to which all patients must come at 
regular stated times if they wish to be attended at labor. 

This patient has again been looked after by the hospital. 
This last time she came to the pregnancy clinic as requested 
with the result that she was operated on early and a live 
baby obtained. 



CICATRIX IN THE VAGINA COMPLICATING LABOR. 471 

The question how to deliver these patients with extensive 
cicatrices in the cervix and vaults of the vagina is many 
times troublesome. (Page 452.) If the scar tissue will relax 
and stretch, then the problem solves itself, but if it does not 
then a vaginal Csesarean section or a manual or instrumental 
dilatation must be done. A vaginal Caesarean with a large 
full- term baby is a very difficult operation. If much 
scar tissue is present it is dangerous. A manual dilatation 
in such cases is no dilatation at all ; it is purely a divulsion, 
and in careless hands is also very dangerous. Even in careful 
hands the outcome is always problematical. In such cases 
the risk to the mother is less, if an elective Caesarean section 
is done. Patients will not usually submit to a Csesarean 
section, for they do not appreciate the danger they face from 
a hard operative delivery by vagina. 



SECTION XXVII. 
PNEUMONIA COMPLICATING PREGNANCY. 

Case 76. Pneumonia Complicating Pregnancy. Jan- 
uary 25. Telephone message from a physician to-night say- 
ing he wished me to see a patient at once with him who had 
a temperature of 103°; pulse 130, with the question of in- 
ducing labor. 

I met the physician at the patient's house within an hour, 
and he gave me the following history : — The patient is 
within three weeks of term of her second pregnancy. One 
week ago she took an automobile ride, and when she got 
home she was chilled. She had no definite chill. The next 
day she began to cough slightly and to complain of pain in 
the right side of her chest on breathing. The temperature 
has not been taken regularly, and what it was the first four 
days of her sickness the physician did not know. She did 
not go to bed until four days ago. Three days ago her 
temperature in the morning was 101.5°, pulse 130. The 
physical examination was negative. Three nights ago she 
began having uterine contractions accompanied by pain. 
These contractions aggravated the pain she had in her side, 
and she was in so much distress that the physician gave her 
a quarter grain morphia suppository. From this she slept 
fairly well during the night. 

Two nights ago the pain was so severe, he said, from the 
contractions of the uterus that she was given ether at inter- 
vals during the entire night. During the day she has been 
fairly comfortable except for the pain in the right chest. 
She has also had several coughing spells, for which she was 
given morphia. (There has been no accurate record of the 
amount of morphia given.) 

Last night she again was very uncomfortable from the 
contractions and from the pains in the chest, and she was 
again given morphia by mouth and by suppositories. 

473 



474 CASE HISTORIES IN OBSTETRICS. 

Her temperature this afternoon, the physician said, was 
103°, pulse 130. He became anxious about her condition 
and asked me to see her, saying he thought she should be 
delivered at once. 

When I first saw her she was lying in bed raised on several 
pillows, on her right side. Her face is flushed. She does not 
look seriously sick. The rapidity of her respirations was 
noticed at once. Her alae nasi were moving rapidly. Her 
pupils were much contracted. She answered a few of my 
questions, and then had a distressing coughing spell and 
raised some thick, tenacious, rusty colored sputum. I did not 
persist in obtaining any further history from her, but at 
once examined her abdomen. 

Palpation of the Abdomen : — Large-sized baby lying In 
a left position. Head is freely movable at the brim. Fetal 
motion is marked. There is no tenderness present in the 
abdomen. While palpating the abdomen the uterus con- 
tracted twice, but the patient had no pain. No tenderness 
over either kidney region. Fetal heart is 120 to the minute in 
the left lower quadrant. 

Vaginal Examination : — Introitus very blue and re- 
laxed. Feels like a slight bilateral tear of the cervix. The 
cervix is not taken up ; admits to the internal os, two fingers. 
Presenting part is free at the brim. 

The patient is in a profuse perspiration and I asked that 
her temperature be taken again. It was found to be 98°. 
Her pulse was 130, full and bounding. 

I told the attending physician that I could see no reason 
from an obstetrical point of view for inducing labor. That 
her condition was not, in my opinion, due to the pregnancy; 
that there must be something outside the uterus causing this 
temperature and pulse. I then asked him if he was sure 
there was nothing in the chest to account for this rapid 
respiration, which I made to be thirty-eight to the minute. 
He now asked me to listen to the chest, which I did, with 
the following result : 

Heart is not enlarged. Sounds are clear and loud. Per- 
cussion of the chest anteriorly is normal; respirations are 
clear. Expiration is slightly prolonged. She was turned 



PNEUMONIA COMPLICATING PREGNANCY. 475 

now on her left side, and the right chest posteriorly listened 
to quickly. Here at the bas^ is typical bronchial breathing, 
breath sounds and whispered voice sounds markedly in- 
creased. Percussion of the right base gives dulness. I did 
not go over her lungs carefully and completely, for her pulse 
was not now of such good quality. 

Diagnosis: Lobar pneumonia complicating pregnancy. 

I told the physician-in-charge that there is no question 
but she has a pneumonia, and that she probably is in the 
midst of her crisis. I suggested calling an internist, but he 
would not listen to it, and asked what I was going to tell the 
husband. I said I should tell him that she probably would 
be much better in the morning, and would go on to the end 
of her pregnancy with no further difficulty. I advised the 
physician to tell the husband that his wife was at the crisis 
of a pneumonia. This he absolutely refused to do, and as 
the husband asked me no questions I volunteered no infor- 
mation. 

I advised the physician to stimulate the patient as the in- 
dications arose; to stop the morphia entirely, and if it was 
necessary to stop any excessive cough to use codeia. To 
open her bowels thoroughly and to give her more fluids to 
drink. 

I telephoned the physician a week later and he said that 
the patient gradually improved. Since I saw her she had 
had no further rise of temperature, and her pulse gradually 
came down to normal. She still, however, was coughing a 
great deal. 

The final outcome of this case was that she was delivered 
on February loth after an easy labor. She made a fair con- 
valescence, but her cough persisted for sometime. 



This case brings up the management of medical compli- 
cations during pregnancy. In earlier cases the manage- 
ment of cardiac cases has been touched upon. These are 
usually of a chronic type. The present case differs in that 
a pneumonia is acute and of short duration. In these 
complications the fundamental treatment must be directed 



476 CASE HISTORIES IN OBSTETRICS. 

at the complication and not at the pregnancy. Emptying the 
uterus would not have helped this patient in the slightest, 
but on the contrary might have killed her. In general it is 
fair to say that if the pregnancy is not the cause of the com- 
plication there is no reason to interrupt it. Pregnancy 
may aggravate the symptoms, but if the patient is so danger- 
ously sick that it is suggested to empty the uterus one must 
remember that the added strain of the operation may 
turn the scales against her. In the presence of an active 
tuberculosis the uterus should be emptied, but only after a 
consultation. Again it should be emptied when a chronic 
nephritis is evident. 

If in the presence of surgical complications operation is 
necessary for the life of the woman it is to be undertaken, 
but if palliation will carry the patient along until after the 
delivery, it is to be attempted. Operations for acute inflam- 
matory processes within the abdomen in the pregnant woman, 
carry with them a very high mortality, and should be post- 
poned if possible. 



SECTION XXVIII 

THE BABY. 

I have already gone over the list of articles necessary for 
the mother to have for herself in the house ready for the 
delivery ; the list for the baby is now given : 

Olive oil. Nightdresses — flannel, at 

Soft wash cloths. least three. 

Soft linen towels. Shirts — No. 2, silk or silk 

Castile soap. and wool, at least three. 

Bath thermometer. Bands — knit — silk or silk 

Talcum powder. and wool, at least three. 

Sleeping basket. Square flannel shawls that 

Scales. can be washed. 

Bath tub. Flannel one yard, untorn; for 
Diapers, 3 doz., 22 by 44 inches. bands. 
Diapers, 3 doz., 25 by 50 inches. Medicine dropper. 

Slips — nainsook or fine linen, Small clothes horse, 
at least six. 

This list needs no explanation. Whether all the articles 
are obtained or not depends entirely upon how much money 
the family has to spend on the outfit. This list can be cut 
down but little, it can, however, be added to in many ways. 

A study of the various cases shows the history and treat- 
ment of some of the problems that appear in the manage- 
ment of the baby. It does not seem best to give an entire 
new case for the sake of showing clearly the treatment of 
the baby, and therefore, I shall include in this section the 
more important points which constantly come up to the 
obstetrician in dealing with the newborn baby. 

Throughout the previous cases I have constantly shown 
the importance of listening to and recording the fetal heart. 
Too much emphasis cannot be put on this, for it is the only 
way we have of following intelligently the baby's condition. 

477 



478 CASE HISTORIES IN OBSTETRICS. 

Many babies have been lost because of failure to watch the 
heart regularly. 

I have already shown the points to be kept in mind during 
the birth, namely, to free the mouth from mucus, to feel for 
the cord, and to wipe out the eyes, and as soon as the baby 
is born, to drain it thoroughly. Page Ii6. 

Whether the baby cries at once or not depends upon the 
degree of asphyxia that is present. Two degrees of asphyxia 
are recognized; the mild, when the baby is blue and cya- 
notic; the muscles have tone and are more or less rigid; 
and the severe, when the baby is pale and limp, without 
tone and looks to all intents dead. The first is called 
livid asphyxia, and the second pallid asphyxia. In the first 
the baby's heart beat is strong, and the rate rapid, while in 
the second the heart beat is very slow and scarcely perceptible. 

The first type rarely needs any treatment. The stimulus 
of the air on the skin will always make such a baby breathe, 
and it soon will show the normal pink hue of a healthy new- 
born babe. If it should not breathe as quickly as one wishes 
gentle slapping of the buttocks or blowing on its chest will 
at once start respiration. 

A baby born in pallid asphyxia needs the most careful and 
the gentlest handling in order to bring it through the first 
great crisis. A baby in pallid asphyxia is in a very pre- 
carious condition, and because it is in this condition I have 
always felt that anything but the most gentle handling is 
contra-indicated. The baby, of course, is drained thoroughly, 
and then it is put in hot water and kept there. The water 
should be at a temperature that the hand can be held in 
comfortably. Warmth is essential in the treatment of this 
condition. Artificial respiration is then begun slowly and 
deliberately, about eighteen times a minute. If respiration 
does not at once begin, then mouth to mouth insufflation may 
be tried. How efficient this means is I have never yet been 
able to satisfy myself, but that it is of help at times cannot 
be denied, and in extreme cases of asphyxia it should be used. 
The number of times that this procedure will be necessary 
will be very few if more careful watch on the child's con- 
dition is kept than is commonly done. Rhythmic traction 



K 



THE BABY. 479 

on the tongue is another stimulus to respiration and oxygen 
may be passed into the lungs by a small catheter in the 
trachea. Other means have been recommended, many are 
rough and may cause severe injuries to the child. After the 
baby has begun to breathe the less handling it is subjected 
to the better. Many babies born in pallid asphyxia breathe 
for a few hours or days, and then die of an inhalation pneu- 
monia or atelectasis. 

After the baby is born and the cord tied and a sterile 
dressing placed over it, there are four points which the nurse 
and the physician must watch carefully in every case. First, 
it must have sufficient air to breathe; second, it must have its 
body temperature kept up; third, there must be no oozing 
from the cord ; and fourth, the mucus, which is so often pres- 
ent, must not be allowed to block the air passages. These are 
the four fundamental points which must be insisted on in the 
management of the newborn baby its first few hours of life. 

After the mother has been attended to and made com- 
fortable the nurse proceeds to bathe the baby. If the de- 
livery has been a hard operative one, do not allow the baby 
to be washed. The amount of handling that is necessary in 
the giving of the bath does more harm than good. In such 
cases the baby is simply oiled quickly with warm oil, wrapped 
up in warm flannel cloth or absorbent cotton and left alone 
until later when it will have recovered from the shock of 
the delivery. 

The essentials of the first bath are speed, gentleness and 
warmth. Therefore, everything for the bath and for dress- 
ing the baby must be at hand before the nurse sits down to 
give the baby its bath. Just before the child is given its 
first bath, it is weighed. It usually is not weighed again 
until the third day, but from then on for the next month it 
is weighed at the same time daily. Intelligent oversight of 
a baby cannot be given unless it is weighed regularly. A 
nursing baby should gain at least five ounces a week, and if 
it does not investigation of the cause must be made. 

Whether the baby is in all respects normal is determined 
by the physician immediately after the birth, before the cord 
is tied and cut. If for any reason its condition was not de- 



480 CASE HISTORIES IN OBSTETRICS. 

termined then it should be before the bath is given. For the 
normal characteristics of a newborn baby I strongly advise 
that the standard textbooks on pediatrics be thoroughly 
studied; unless the physician knows what is the normal he 
may very quickly become confused. 

The proper management of the baby in its first few weeks 
of life is most essential for its own and the family welfare. 
Regularity stands out as the most important point in the 
care of the infant. Nothing must be allowed to interfere 
with its daily routine. 

A healthy newborn baby should sleep almost continu- 
ously, waking only to nurse. Gradually, as it grows older, its 
waking periods are longer, but when it is awake it lies in 
its bed perfectly contented. A baby may cry off and on 
during the day, but if healthy and well fed, never continu- 
ously. The characteristic cry of the spoiled baby is, un- 
fortunately, too commonly heard. Discipline is as essential 
for the newborn baby as it is for older children. 

The question of nursing I shall take up later in this section. 
After the baby^s first tub bath it is not given another until 
the umbilical cord is off and the umbilicus has been dry for 
at least forty-eight hours. Each day the baby is given its 
bath with a face cloth, care being taken not to moisten the 
cord dressing. The cord dressing is held in place by the 
flannel band torn of sufficient size to hold the dressing 
firmly in place. The dressing must be kept dry, but if it 
becomes wet the original dressing should be taken off and a 
fresh sterile one applied. If the cord becomes moist, it is 
best treated with 70% alcohol, and then powdered with 
subgallate of bismuth. The objection to aristol is that in 
not a few babies the skin is irritated by it, and also the cost 
is much greater than the subgallate. The cord drops off in 
from three to ten days, — the variations are great, and for 
no obvious reason. Various methods of treating the cord 
have been suggested from time to time, but none is more 
satisfactory than simply leaving it alone to dry up. After 
the cord separates, the umbilicus is powdered with the sub- 
gallate of bismuth and in a few days it cicatrizes and soon 
shows the normal dimpling. Not infrequently the moisture 



THE BABY. 48 1 

persists, and this usually is due to a granuloma at the base 
of the umbilicus. Careful touching of this granuloma with 
the silver nitrate stick will quickly make the umbilicus heal. 
Occasionally, in neglected cases, the granuloma is large and 
pedunculated, and in these cases ligation gives the best re- 
sults. The umbilicus is carefully wiped out with 70% 
alcohol, and then a sterile ligature is passed about the base 
and tied tightly. It should be unnecessary to add that one's 
hands must be absolutely clean if this is done. If the normal 
dimpling at the umbilicus is not present watch must be kept 
up to see that no bulging takes place. If the umbilical ring 
does not completely close at once, then the umbilicus must 
be strapped with adhesive plaster. There is no object in 
waiting. Even with only a small amount of crying a ring, 
imperfectly closed, will stretch and an umbilical hernia occur. 
Strapping is not to be done unless the umbilicus is absolutely 
dry. If it is moist, the band must be continued until it has 
entirely healed. The strapping should be put on across the 
belly so that a slight longitudinal furrow is produced. 
Treated early and efficiently imperfect closures of the um- 
bilical ring always heal solidly and give no trouble. Un- 
treated, the ring steadily enlarges, and an umbilical hernia 
develops. If strapping does not make the ring close, it must 
be closed by an operation. An operation, however, is very 
rarely necessary. 

Fresh air is essential to the baby's growth and develop- 
ment. How to obtain this fresh air is a problem only in the 
winter time, for in the summer with the windows open and 
houses not heated, there is no difficulty. Sudden chilling 
of a newborn baby must be avoided in winter or in summer. 
By the end of a week after birth, the room, if the baby is a 
winter baby, may have a temperature of 65° F. Gradually, 
as the baby thrives, the windows may be opened wider and 
the air in the room by the end of the second month may be 
down to 50° F. Few babies, however, will stand at this age a 
temperature below freezing. Each baby must be carefully 
watched to see how it reacts to cold air. Cold air is not 
essential; it is fresh air and sunlight that the newborn baby 
needs. Winter babies need not be taken out of doors, pro- 



482 CASE HISTORIES IN OBSTETRICS. 

vided they can be put in a sunny room with the windows 
opened, as the temperature permits. After the first month 
winter babies may be put out of doors in the sun for short 
periods, provided the weather is not extreme, and dust is 
not flying about. Summer babies may be put out on a 
sunny piazza by the end of the first week for a short time each 
day. By the end of the third week they should be outdoors 
practically all day. 

I have already spoken of wiping off the eyelids at birth 
with a 4% boric acid solution. As soon as possible after 
birth a drop of argyrol 25% should be dropped into each 
eye. If argyrol is not used then a 1% solution of silver 
nitrate may be substituted. Both are efficient preventives 
of ophthalmia neonatorum and one or the other should be 
used in every obstetric case. If it is known that a gon- 
orrhea is present in the mother, the silver nitrate solution 
should be used regularly after thorough irrigation. Should 
a severe ophthalmia develop, efficient treatment by irrigation 
and by the silver salts must be at once instituted. Efficient 
treatment demands skilled nurses working under the super- 
vision of oculists. If such treatment cannot be obtained at 
home the baby and mother should be sent to the proper hos- 
pital. At the present time practically no hospital will take 
both mother and child when the child has ophthalmia. It is 
a very serious thing to take a newborn baby off the breast, 
and therefore, every effort must be made to have efficient 
treatment carried out at home. Blindness in the newborn 
from gonorrheral ophthalmia is almost positive proof that 
someone has badly erred in the treatment. It is a terrible 
criticism of some members of the medical profession in Mas- 
sachusetts, that of the number of blind or partially blind 
babies of whom the Massachusetts Commission of the Blind 
has record during the past few years, many have been at- 
tended by physicians in supposedly good standing. 

In the care of the vulva in female babies, cleanliness is 
essential and in order to remove the smegma secretion some 
oily preparation should be used. Albolene is satisfactory. 
Not infrequently a girl baby has a slight bloody discharge 
from the vagina for a few hours or days. If it is not the 



THE BABY. 483 

bleeding from hemorrhagic disease of the newborn it is 
called precocious menstruation. It does not mean, how- 
ever, that this will appear each month as the child grows 
up. In male babies the early retraction of the foreskin and 
careful cleansing of the penis tends to the comfort of the 
baby when he grows up. Circumcision is seldom needed, 
but many times the parents request it. 

Not infrequently a nurse will report that a diaper has been 
changed and blood found on it. On investigation it is seen 
that what is reported as blood is in reality fine reddish gran- 
ules, the characteristic deposit of urates oftentimes seen in 
newborn children's urine. This can readily be proved by 
dipping the stain in hot water when the urates dissolve and 
disappear while if it were blood it would still remain. When 
this stain is found boiled water in dram doses should be 
given the baby between the feedings to help flush the kidneys. 

Hemorrhagic disease of the newborn is not an uncommon 
condition. The cause of this disease is still unknown. Any 
bleeding that occurs in the newborn child must be regarded 
as hemorrhagic disease until it is definitely proved not to be. 
The first sign that any bleeding has taken place may be the 
vomiting of blood. This blood may be old dark blood, the 
sign of past bleeding or it may be mixed with fresh bright 
blood. Blood may first appear in the stools or ecchymotic 
areas may be found in the skin. The bleeding may be from 
the umbilicus; bleeding here is oftentimes serious and very 
difficult to check. The baby may show bleeding from many 
places or it may have but one severe hemorrhage, as did the 
baby in Case 28. Multiple bleeding is usually more serious 
than when one type alone prevails. 

Hemorrhagic disease of the newborn is always a serious 
condition. At the first sign of bleeding a definite prognosis 
cannot be given, for no one knows how soon the baby may 
bleed again or how severe the bleeding may be, if it does 
recur. A careful physical examination will help in the prog- 
nosis. The baby's color, its respiration, pulse rate and tem- 
perature must be noted ; in general, the greater the variations 
these show from the normal the more serious is the prognosis. 
The treatment of this disease is first absolute rest and quiet. 



484 CASE HISTORIES IN OBSTETRICS. 

The baby should be taken off the breast, except in the very 
mildest cases, and if feeding is needed breast milk should be 
given by the bottle or dropper. The body heat must be 
kept up. The various drugs that have been recommended 
generally do not do the slightest good. If improvement fol- 
lows their use the probablity is that the baby would have 
improved anyway. Subcutaneous injection of thirty cubic 
centimeters of fresh rabbit serum has given good results in 
not a few cases, and if it can be obtained it may be given. 
Human serum, more difficult to obtain, has also been used. 
With the great advances in the technique by which trans- 
fusion of blood may now be done this procedure undoubtedly 
offers, at the present time, the best hope for the baby. A few 
years ago this operation, because of the difficult technique, 
was used only as a last resort, but now it should not be 
postponed until the child is moribund; but even if mori- 
bund, it must, if possible, be done, for brilliant results are 
already being reported. Every hour the baby lives without 
recurring bleeding the prognosis improves. Careful nursing 
in such cases is of prime importance, and each step in bring- 
ing the baby back to the usual routine must be carefully 
considered, but when one is confident that the bleeding has 
ceased the baby may be treated as any normal baby. 

Jaundice of the newborn is of so constant occurrence that 
one almost has come to look for it in every child. Simple 
jaundice needs no treatment, for it always clears up of itself 
very quickly. Calomel must not be given. In another type 
the jaundice increases, the stools are clay colored, and 
the child gradually loses ground and dies. This type is due 
to the congenital obliteration of the bile ducts and admits 
of no treatment. 

Not infrequently the breasts of the newborn babe are en- 
larged, and sometimes reddened. When the breasts are 
simply enlarged and full, no treatment should be given save 
to take especial pains that the breasts are in no way pressed 
upon. If they become reddened and fluctuate with other 
signs of abscess formation they must be opened and drained 
as any other abscess would be. If the breasts are left alone 
they seldom break down, but if rubbed it is not uncommon 



THE BABY. 485 

to have an abscess form. The name commonly given this 
condition is mastitis, but as there is, in the great majority of 
cases, no rise in temperature, no heat or redness present, the 
condition is not inflammatory and therefore, rightly, should 
not be called a mastitis. It becomes a mastitis after the 
breast is infected, usually from manipulation. 

These are the more common diseases which the obstetrician 
meets in the newborn child. Careful complete physical ex- 
aminations must be made whenever the child acts differently 
from what is normal. What the normal is can only be 
known by careful observations on many children. If a 
physician has not had the clinical opportunity to examine 
many normal children, he should avail himself of the real 
demand that is put upon him to examine at birth, or as 
soon after as possible, each baby of which he has charge. 
By constant observation he will quickly learn to appreciate 
abnormalities. 

Resulting from the labor, sometimes in normal deliveries, 
at other times from hard operative deliveries, a group of in- 
juries occur which the physician must recognize. The com- 
monest in this group are as follows : 

The compression of the fetal head resulting in the so-called 
moulding is so common as to need but passing mention. 
The one thing to remember is that a moulded head will 
always return to a normal condition. It never needs manipu- 
lation. The only advice that need be given in such cases is 
that the baby be placed in such a position in its bed that the 
most prominent part of the skull is down on the mattress in 
order to favor rapid return to the normal contour of the skull. 

After a hard long labor with ruptured membranes, and 
after operative deliveries the baby may show signs of in- 
tracranial hemorrhage. Occasionally this condition may 
come after a normal labor. The first sign that is usually 
observed in this condition is loss of the normal pink hue to 
the baby*s skin. It then nurses poorly and not infrequently 
regurgitates part of its feeding. The temperature Is elevated 
and the pulse rate rapid. Disturbance of respiration with 
varying degrees of cyanosis is very common. Physical ex- 
amination shows usually a tense, oftentimes bulging, anterior 



486 CASE HISTORIES IN OBSTETRICS. 

fontanelle. There may be twitchings of the extremities, one 
or all, or paralysis of one side may be marked. A general 
convulsion is not infrequently seen, and may be the first 
sign of anything wrong. Bleeding from the nose I have 
noted in several cases. The finding of blood in the lumbar 
puncture is positive evidence, but if not found it does not 
prove that a cerebral hemorrhage is absent. 

The prognosis in such cases is grave. If these babies live 
the blood clot is gradually absorbed. If the blood is entirely 
absorbed, and no pressure symptoms develop, the child may 
grow up to be normal. If it is not absorbed various degrees 
of mental aberrations later become manifest. 

The treatment is either to do nothing and hope for reso- 
lution, or to operate and turn out the clot or simply to open 
the skull, incise the dura and drain without any further 
manipulations. The parents should be told the prognosis 
with and without operation, and the danger of operation must 
not be minimized to them. The final decision must be with 
them, and the surgeon's enthusiasm must not be allowed to 
carry them away. If the operation is successful, and a few 
have been, the prognosis is much improved. Is it not better 
to attempt the cure rather than to have the child turn out 
feeble-minded? 

A caput succedaneum is an edematous swelling present at 
birth, due to the subcutaneous serous infiltration at the 
point of the presenting part where there was no pressure, 
that is, at the os uteri. It varies much in size, it is soft, 
pliable, and not limited to one bone. It appears only where 
there is delay in the progress of the labor or where labor is 
very slow. It is formed after the rupture of the membranes 
by the interference with the return of the venous blood while 
the arterial blood is still coming to the part. It may ap- 
pear at any point of the child's anatomy that is at the os 
uteri during labor. It requires no treatment, for as soon as 
the delivery is completed the circulation is unimpeded, and 
the edema rapidly disappears. 

A cephalhematoma, in distinction to the caput, never ap- 
pears until after birth, generally in from eighteen to thirty- 
six hours. The cause of this condition is a rupture of a 



THE BABY. 487 

blood vessel and hemorrhage between the periosteum, and the 
bone. It is located on one or the other, or on both of the 
parietal bones, posteriorly. A cephalhematoma is always 
limited by the edges of the parietal bone on which it starts. 
It usually increases in size for the first twenty-four hours 
after its appearance in marked contra-distinction to the 
caput. It is firmer and more resilient than the caput. The 
prognosis is absolutely good, and no treatment is demanded. 
Its absorption is slow. The larger the mass, naturally the 
longer will be the absorption in taking place. From three to 
nine weeks is a fair statement of the time needed. In the 
process of absorption the periosteal ring is readily felt as a 
hard raised edge, and it is often another month before this 
edge has completely disappeared. The occurrence of a 
cephalhematoma cannot be stopped, and in no way can it 
be blamed to the physician, whether the case be a normal or 
an operative delivery. 

Fractures of the clavicle or of the long bones in difficult 
versions or breech extractions are not uncommon, and must 
be treated on recognized surgical principles. Fractures in 
the newborn knit very quickly and the prognosis is excellent, 
except in the very rare condition where there is a deficiency 
of lime salts. 

Fractures of the cranial bones may occur spontaneously 
as the result of excessive moulding or because of damage 
done by the improper use of forceps. A spoon-shaped de- 
pression of the cranial bones occasionally follows a labor in 
a contracted pelvis, especially in the fiat pelvis type. It is 
due to the pressure of the promontory on the bone, as it is 
forced by. (Case 22) If a forceps delivery is undertaken 
after the biparietal diameter is forced through the brim, and 
this depression is found, unless the physician explains to the 
parents the cause of the condition he is unjustly blamed for 
it. If the depression is slight, it needs no treatment, for it 
will right itself. If it is marked, pressure at the ends of the 
depression will sometimes buckle out the hollow. If it does 
not come out by this simple means it should be raised by a 
tenaculum passed in through a small trephine opening, or 
by some other satisfactory means. 



488 CASE HISTORIES IN OBSTETRICS. 

Facial paralysis following a forceps delivery is very com- 
mon. It is caused by pressure of the forceps tip on one or 
the other of the facial nerves. It always clears up, generally 
within forty-eight hours, without treatment. 

Paralysis of the arm, obstetrical paralysis, may come after 
any delivery if the head is pulled too strongly, or if the de- 
livery is a breech, if the body is given too great and poorly 
directed traction. The damage here is due to the stretching 
or rupture of the nerve roots. The arm hangs limp by the 
baby's side, with inward rotation of the hand. The prognosis 
is always guarded, but with intelligent oversight, massage, 
manipulation and exercises as the baby grows up great im- 
provement may be confidently expected. 

Not infrequently, in normal deliveries, though more often 
in hard long drawn-out labors, a bright red spot is noticed at 
the end of twenty-four or thirty-six hours in one or both 
eyes. The condition is one of subconjunctival hemorrhage, 
and is due to a slight hemorrhage following the compression 
the skull is subjected to during delivery. It never requires 
treatment, but the parents must be assured that no damage 
can arise from it. 

Very rarely a swelling of varying size is found along the 
sterno-clido-mastoid muscle. This condition usually is seen 
after a breech delivery, and is due to the rupture of a small 
vessel within the sheath of the muscle and its contour is, 
therefore, usually ovoid with the long axis parallel to the 
muscle. The name given this condition is a hematoma of 
the sterno-mastoid muscle. Usually the hemorrhage is ab- 
sorbed in the course of a few weeks. Very rarely it may 
give rise to a torticollis and operation may become 
necessary. 

For a consideration of the various malformations that may 
occur the reader is referred to the standard textbooks, for 
they are beyond the scope of this book. The only ones that 
here need to be mentioned are the imperforate anus which 
calls for surgical interference at once and tongue tie which 
may be so marked as to prevent the baby from nursing 
properly. Here again is seen the necessity of making a 
complete inspection of the baby as soon as is possible; the 



THE BABY. 489 

usual time, as already mentioned, is after the birth of the 
child, before the cord has stopped pulsating. 

It usually falls to the physician who has delivered the 
baby to start it on its nursing career. I say nursing ad- 
visedly for every baby should, if possible, be nursed. No 
matter how skillful a physician may be in feeding babies 
upon modified milk, modified milk is at best but a substi- 
tute for maternal nursing. The attitude that not a few 
physicians take that babies can be brought up as well on 
the bottle as on the breast must be roundly condemned on 
every possible occasion. At the present time, even among 
the very well to do, mothers will nurse their babies if the 
physician and the nurse take a decided stand for nursing. 
The nurse can turn the mother from nursing by unguarded 
remarks, and if the physician too is not enthusiastic it is 
only a few days before conditions are such that from his 
point of view weaning must take place at once. 

There are certain maternal conditions which must be ful- 
filled for successful nursing. That all these conditions are 
present in all cases is not to be supposed, but they are in the 
majority of cases if the infant does well. The mother must 
want to nurse her baby in order to nurse successfully. She 
must place everything secondary to nursing. Regularity is 
the keynote of a nursing woman's life. She must be healthy, 
she must lead a sensible life with sufficient amount of exer- 
cise in the open, she must have good food that is readily 
digested. She may eat anything that she can digest; no one 
kind of food is to be eliminated from her diet because it is 
thought this or that will upset the baby. A generous, full, 
well-balanced diet is the best for a nursing woman. As a 
general rule women with even temperament, those not easily 
disturbed by household worries and the like, make the best 
nursing mothers. Not infrequently, however, one sees the 
neurotic, high-strung girl settle down and nurse her baby 
successfully. Cares and worries must be removed as far as 
possible from the nursing woman. Everything in her daily 
life must be made easy for her. 

Her physical condition must be carefully guarded, and if 
it is found that she is losing weight, below her normal weight, 



490 CASE HISTORIES IN OBSTETRICS. 

then the question of weaning the baby must be considered. 
Some patients put on weight rapidly while nursing, because 
of the added amount of food they take. Patients of this 
type one does not worry about, but in the opposite type the 
decision to nurse or not to nurse is oftentimes a difficult one 
to make. 

A nursing woman must have, at least, one dejection a 
day; if she is unable to have it naturally she must use a 
laxative or an enema, or combine these. If the patient can 
get along without drugs, relying on fruits and laxative foods, 
drugs need not be resorted to, but while she is nursing is 
not the time for her to attempt to rid herself of the necessity 
for taking laxatives. What laxative she takes, provided it 
is not one of the salines, is unimportant. She must not, as 
is so common, be allowed to take Epsom salts. 

Menstruation occurring in a nursing woman is of itself no 
contra-indication for nursing. Each individual case must be 
determined by the effect menstruation may have on the 
milk, and therefore, on the baby. Let it be clearly under- 
stood that there may be no effect, and this usually is the 
case. Therefore, there is no indication for stopping nursing. 
From normal condition to severe gastro-intestinal upsets in 
the baby, all gradations may be met. One upset, unless it 
is very severe, is not sufficient reason to wean the baby. A 
second menstruation is awaited, and if the baby is again 
seriously disturbed, nursing will have to be given up. Even 
if the baby is disturbed for from one to three days during 
the menstruation and then recovers quickly any ground 
that has been lost, and makes further satisfactory gain 
before the menstruation again appears, there is no indi- 
cation to stop nursing. The first menstruation after par- 
turition may be very profuse, and recognizing this fact we 
may confidently look forward to the second being more 
nearly normal. In speaking of menstruation during nursing 
it may be well to recall to not a few physicians the following 
facts: Menstruation may be established four weeks after de- 
livery, or it may not appear for weeks after the nursing 
period is over. No physician can truthfully say what this 
or that patient will do. What she has done in one nursing 



THE BABY. 491 

period she very likely may repeat in another, but of that there 
is no certainty. Menstruation once established, may then 
recur regularly, as was its custom before pregnancy began 
or it may show slight irregularities both in time and amount 
for a few months. Because no menstruation appears the 
laity and not a few physicians think no pregnancy can 
occur. Such is far from the truth. Any woman during her 
child-bearing period, who has intercourse, may become 
pregnant at any time, whether she is menstruating or not. 
The process of ovulation goes on whether menstruation is 
present or not. This is conclusively proved by the well- 
known fact that women have baby after baby without ever 
having a menstrual period from the time they are married. 

Pregnancy, unfortunately, may occur while the mother is 
nursing. It is inexcusable, for if a pregnancy does begin 
nursing must then be given up, and the first baby suffers as 
a result of the new gestation. The mother in this circum- 
stance does not have time to recuperate. Breeders of 
animals do not allow gestation to follow so quickly, but the 
uncontrolled animal, man, does not hesitate to subject his 
wife to one pregnancy after another without sufficient time 
for recuperation. 

During the minor acute illnesses of the mother nursing 
should be continued. In not a few cases where the maternal 
temperature is high, the milk may go entirely or become 
much diminished in amount. In such cases, where there is 
insufficient amount of breast milk, supplemented modified 
milk should be used temporarily. As the temperature drops, 
if nursing is persisted in, in the majority of cases the milk 
will return. Patients with tuberculosis, epilepsy, nephritis 
and malignant disease should not be allowed to nurse. A 
patient with syphilis, on the other hand, should nurse her 
own baby, but on no account, another baby. 

On the nurse who is with the patient devolves the re- 
sponsibility of carrying out the physician's wishes in regard 
to actual nursing. As has been already stated, the first 
nursing begins after the patient has had a sleep after the 
labor is completed, some twelve hours later. Regularity the 
first twenty-four or forty-eight hours is not sought, for there 



492 CASE HISTORIES IN OBSTETRICS. 

are many factors which will interfere with this point. If the 
baby cries a great deal, its restlessness may be quieted by 
teaspoonfuls of boiled water. If the milk is slow in appear- 
ing and the baby becomes very hungry, then a weak modified 
milk should be given in small amounts. At the beginning 
of nursing the baby nurses from two to three minutes on 
each breast, as there, in all probability, is not enough milk in 
one breast to satisfy the baby. Gradually, as more milk 
comes into the breast, the regular nursing period becomes 
established. The question whether to start the baby at 
once on three or four hour feedings each physician must de- 
cide in each individual case. Not a few babies do better on 
three hour feedings than on two. In the West and in Ger- 
many many babies, at once, are put on four hour feedings. 
It is desirable to get the baby on three hour feedings as 
quickly as is possible, for it gives the mother greater freedom. 
The important point to remember is that one must not shift 
from three to two hour feedings and vice versa without fair 
trial of the one or the other schedule. In the nursing the 
baby must not be allowed to get the milk too rapidly, if 
necessary, it must be taken off the breast every three or four 
minutes, and made to rest for two or three. By this scheme 
one may break up the habit of rapid nursing and its conse- 
quent evils. 

How long to nurse must be settled by the mother and 
nurse. Some babies will get all the milk they need to carry 
them along to the next feeding in ten minutes, while others 
need periods of twenty minutes. If a baby, after twenty 
minutes of good nursing, does not obtain enough milk to 
satisfy it, there is never any object in keeping the baby nursing 
longer. This is sufficient evidence that the supply is inade- 
quate. To be absolutely certain that the supply is in- 
sufficient, the baby should be weighed with its clothes on 
before and after each feeding for one day. By this means 
one at once knows absolutely what amount of milk the baby 
obtains. 

The signs of a successful nursing are a steady, satisfactory 
gain in weight; the baby sleeps the greater part of the time, 
wakes just before nursing time, and as soon as nursing is 



THE BABY. 493 

over goes to sleep again or lies in its basket contented. There 
is no vomiting, and no colic; but an occasional gas pain last- 
ing a few moments is not unusual. The baby cries but 
little except when wet or soiled. The movements are smooth, 
yellow, without mucus or curds and in number they vary 
from one to ten. Not infrequently a nursing baby may have 
green movements with curds and yet gain satisfactorily. No 
alarm should be felt because of these movements. Gradually 
the movements drop in number to one a day, and not in- 
frequently a movement every other day is apparently suffi- 
cient. Again and again babies have been reported to me as 
being constipated, and on careful inquiry the constipation 
consists merely of having a movement every other day. The 
stool itself is of normal characteristics and the baby shows no 
discomfort. In such cases, it has never seemed to me ad- 
visable to begin giving the baby any medicine to make it 
have a movement every day, nor has it seemed best to use 
the soap-stick in order to stimulate the bowels to move. If 
the baby is uncomfortable and fussy a movement every 
other day is not sufficient. The condition must be corrected 
and usually small doses of milk of magnesia will at once 
straighten out the baby. 

The signs of insufficient nursing are the opposite from 
those just related, but the most characteristic sign is the 
wakefulness and irritability that the baby shows. The other 
signs are, however, present. 

If the milk supply is insufficient and cannot be increased, 
then other means for feeding the baby must be sought. Is 
there any way to increase the milk supply of a nursing 
woman? A regular life, good and sufficient food, with a fair 
amount of fluids, together with a good nursing baby is the 
only way. If under these circumstances the milk is in- 
sufficient, the forced feeding of much milk, gruels, cocoa, beer 
and the like will not make, for any appreciable length of 
time, much gain in the amount of milk. It is more than 
likely to upset the mother's digestion. 

The method of weaning the baby will many times have to 
be decided by the physician. The usual way of putting on 
the breasts a tight compression binder, of giving Epsom salts 



494 CASE HISTORIES IN OBSTETRICS. 

in divided doses, and the restriction of the liquids is to-day 
an unnecessary hardship on the mother. The most satis- 
factory way is to leave the breasts alone. They will fill up, 
become tense, engorged and tender for twelve hours and 
then rapidly go down. If the tenderness is marked an ice- 
bag to each breast will give immediate relief. In a small 
number of cases codeia in small doses will materially com- 
fort the patient. In private work, where the quick and 
complete drying up of the breasts is often not so urgently 
needed as in hospital work, the breast pump may be used to 
good advantage. The objection to its use is that the breasts 
then secrete more milk, and the drying up process is pro- 
longed, and also there is the slight added danger of infection. 
If the breasts are pendulous, a supporting binder is put on 
for comfort. The bowels are moved daily, but drastic purg- 
ing is never necessary; neither is it necessary to limit the 
amount of fluids ingested. This method of drying up the 
breasts has proved very satisfactory. I have not, in ten 
year's work, used any other method, and many patients, who 
have been subjected to the first mentioned way have grate- 
fully spoken of this latter method. When weaning may be 
done gradually, by the substitution of one bottle after another, 
the process is more easily accomplished with practically no 
discomfort to the mother. From the point of view of the 
baby gradual weaning is always to be preferred. The above 
method is just as satisfactory, however, whether the nursing 
is to be stopped a few days or a few months after it has been 
established. 

If the mother is unable for any sufficient reason to nurse 
the baby, the problem of bringing the child up on the bottle 
arises. This book is not the place to discuss the questions of 
modified feeding, but as the physician, who is present at the 
birth, must frequently start the baby on a bottle, there are 
certain fundamental points, which it is not out of place to 
call to the reader's attention. 

First and foremost is the source of the milk supply from 
which the modified milk is to be made. If possible, the milk 
should be from a certified herd of cattle ; if that is impossible, 
then at least from a tuberculin tested herd kept under clean 



THE BABY. 495 

conditions. The herd should be a mixed one of Guernseys, 
Holsteins, and Ayrshires, in such proportion that the fat 
content of the milk will be constant in the neighborhood of 
4%. The fresher the milk the better for the baby. Given 
a good clean milk, the necessity for safeguarding its purity 
must be insisted upon when it comes into the patient's 
house. The method of making up modified milk I shall not 
go into here. The one essential point for the physician to 
remember is that a newborn babe must be put on a weak 
formula and that a low fat content is of prime importance. 
Remember to start with a weak formula and give small 
amounts. It is much better to underfeed a bottle baby than 
to overfeed. The damage done from overfeeding, especially 
from a high fat content, is very serious, and lasts many 
months. The details of modified milk must be mastered, 
and the reader is referred to the standard textbooks of 
pediatrics for this knowledge. 

Comparatively few physicians appreciate the importance 
of guarding the newborn babe from being chilled. One 
single serious chilling may kill a normal full-term child. 
This being true in regard to the full-term child, it is many 
more times important that the premature baby be guarded 
in every possible way. When a physician is called to a pre- 
mature delivery, one of the first conditions which he must 
see is complied with is that the room in which the delivery 
is to take place is warm. A temperature of 75-80° is neces- 
sary. Of course, when the labor is but two weeks premature, 
there is no need to have the room as warm, but if the labor is 
two months premature then the room must be as noted. 
As soon as possible, the baby must be surrounded by warmed 
coverings. A premature baby must never be done up in 
materials that have not previously been warmed. The two 
fundamental points in the management of the premature 
baby are maintaining its body temperature and obtaining 
breast milk for it. In order to carry out successfully the 
first point a day and a night nurse are necessary. Careful, 
constant vigil is essential. A premature baby must not be 
washed at birth; it is quickly oiled with warm oil, not dressed, 
but surrounded by absorbent cotton, and heaters are put 



496 CASE HISTORIES IN OBSTETRICS. 

about it. The pediatricians in whom I have confidence do not 
advise the use of incubators for premature children, and as 
I have seen many children thrive without the incubator, and 
some die in the incubator, I have never attempted to use 
one in private practice. Definite rules for the management 
of every premature baby cannot here be laid down; only 
the fundamentals will be attempted and variations must be 
expected in each case. 

The room in which the baby is, must be quiet, darkened 
and have a temperature of about 80°. The basket in 
which the baby lies must be padded to avoid draughts, and 
the thermometer placed in the basket near the baby should 
record 90-95°. The baby's temperature should be taken 
every four hours and heat added or taken away depending 
on whether the child's temperature is below or above normal. 
Slight variations in the temperature, the first few days, in a 
markedly premature baby are not unexpected, but gradually 
the temperature comes to be more steady. The nurses must 
be instructed to handle the baby as little as possible. Visi- 
tors should be kept out of the baby's room. Human milk, 
if possible, should be obtained for the baby. If there is no 
milk in the mother's breast, a wetnurse must be obtained 
if the child is to have every possible chance to live. 
That excellent plan — the Wetnurse Directory — which has 
recently been established in Boston gives the Boston 
physicians the opportunity of obtaining breast milk that but 
few parts of the country have. If a wetnurse is to be used 
her physical soundness and the absence of syphilis, as shown 
by the Wasserman reaction, and the absence of gonorrhea, 
must be guaranteed by the Directory, or if not obtained 
there, must be by the physician who is in charge of the case. 
The more premature the baby the more essential is it that 
breast milk be obtained for it. It is unwise to attempt to 
nurse many premature children, for the exertion of nursing 
with the necessary handling that nursing entails tires these 
children too much. Feeding by a dropper or by means of a 
Breck feeder is much more advisable. In the first few days 
of a premature baby's life it may be necessary to dilute the 
mother's milk. There can be no set rules for the manage- 



THE BABY. 497 

ment of such babies. The underlying rules of giving small 
amounts of breast milk often must be remembered. The 
physician carefully feels his way along remembering always 
that the baby is premature, and all changes must be made 
slowly and carefully. Gradually, as the baby grows older, 
the room temperature and the basket temperature are re- 
duced. The food is increased in amount, and the feeding 
intervals lengthened. One nursing a day is attempted, and 
if it goes well then more follow. Each change is an experi- 
ment, and one must be ever ready to go back or forward ac- 
cording to the present indications. The successful rearing 
of a markedly premature baby is a triumph, but the physician 
must not gather to himself the honor. The nurses in charge 
of such an infant and the mother who does as she is advised, 
in order to give the baby breast milk, deserve much more 
credit than does the physician. The physician outlines the 
care and the efficient nurse carries out the minutest detail 
as ordered. Without team work satisfactory results will not 
be obtained. 



INDEX. 



A. 

Page 
Abderhalden's serum reaction 33 

Abortion (see Miscarriage). 

Abortion in heart disease 405 

Inevitable 35 

Tlireatened 37 

Blood clots by vagina in 37 

Examining in 45 

Hemorrhage in 37 

Length of time in bed in 47 

Morphia in 37 

Pains in 38 

Treatment of 46 

After-coming Head, Forceps to 245 

Albumin, Presence of, in urine 86 

Alcohol Douche in sepsis 362-367 

Alcohol in sepsis 370 

Anaesthetics in labor 131 

in operative deliveries 161 

Anterior Foot, Importance of seizing in performing version 244 

Anterior Uterine Segment, Thinning of 143 

Areola, Increase in color of, in pregnancy 32 

Argyrol, Use of, as preventive of ophthalmia 482 

Asphyxia, Livid 478 

Pallid 219, 251, 414, 478 

of the baby 76, 478 

Treatment of, of the baby 478 

Auscultation, of the fetal heart 94 

Automobile, Use of, in pregnancy 18, 51, 87 

Automobile Miscarriage, Characteristics of 44 

B. 

Baby, The 477 

The bathing of 479 

Condition of, during delivery as shown by circulation of the scalp 76, 113 

Physical examination of 479 

Weighing of 479 

Babies of eclamptic mothers. Treatment of 349 

Baths in the puerperium 124 

Hot, in toxemia of pregnancy 320, 331 

Bed Blocks loi 

Bier Bells, Technique of the use of, in breast abscess 396 

Bi-iscHiAL Diameter 96 

499 



500 INDEX 

Page 
Bladder, Distention of, during labor 328 

Washing out of 381 

Bleeding from edematous anterior lip of cervix 151 

in early pregnancy 28 

Bleeding in high blood pressure 347 

Use of, in eclampsia 335, 336 

Blighted Ovum 40, 42 

Blood Pressure in eclampsia . . . ; 335 

in pregnancy 86, 342 

in toxemia 318, 319 

Blunt Hook, Description of 193 

Use of 460 

Use of, in breech deliveries .• 181 

Braxton Hicks' version in placenta prsevia 272 

Breast Abscess, Use of Bier Bells in 395 

Dry gauze dressing in 392 

Ethyl chloride anaesthesia in 396 

Medical incision of 400 

Summary of treatment of 371 

Surgical treatment of 391, 490 

Breast Binder 126 

Breast Pump, Use of, In drying up the breasts ; 494 

in mastitis 399 

Breast Tray 126 

Breasts, Care of, in pregnancy 88 

in the puerperium 125 

Changes of, in pregnancy 3i» 33 

Drying up of the 252, 403 

Prickling sensations in I9» 32 

Breech, Delivery of 173 

Extraction of 180 

Extraction of, in a primipara 183 

Palpation of 173 

Breech Delivery, Assistance in 190 

Extension of the arms in 185 

Management of 185 

Importance of watching fetal heart in 190 

Instruments used In 193 

Early rupture of the membranes in 175 

Fracture of the femur in 181 

Obstetrical ether in 191 

Prognosis for the baby in 197 

Breech Delivery, and extraction. Summary of 189 

Technique of 177. 184, 195 

Voorhees bag In 188, 192 

Breech Presentations, Danger from 190 

Delivery in dorsal position in 193 

Ether in I94 

External version in 19^ 

Morbidity from I97 

Rupture of membranes in 192 



INDEX 501 

Page 

Bromides, Use of, In nausea and vomiting of pregnancy ... 307 

in puerperal insanity 428 

Bronchitis in the puerperium 178 



C. 

Cesarean Section 294 

for breech presentation 193 

Contraindications for 230 

in accidental hemorrhage of pregnancy 249 

in eclampsia 347 

in heart disease 419 

Indications for 283 

in placenta praevia 272 

Technique of 292, 294, 304 

in toxemia of pregnancy and rhachitic dwarf 333 

Caput Succedaneum 140, 284, 468 

Definition of 486 

Treatment of 486 

Care of patient during pregnancy 90 

Castor Oil, Use of, in the puerperium 123 

Catheter, Use of, in rupturing the membranes 458 

Catheterization of the patient before operative delivery 162 

Technique of 124 

Cephalhematoma 286, 416 

Definition of 486 

Prognosis of 487 

Treatment of 487 

Cerebral Hemorrhage of the new born 160 

Cervix, Edema of the anterior lip of 184 

Chill, Post partum 122 

in the puerperium 220, 336 

Chilling, Seriousness of, of the new born 495 

Chin, Posterior position 351 

Cicatrical Band in the vagina 384 

Cicatrix of the cervix, Method of delivery in 470 

in the vagina, Manual dilatation of 467 

in the vagina, complicating labor 467 

Circulation in the baby's scalp, during delivery 76, 113 

Circumcision 483 

Clavicle, Fracture of 487 

Clothes in pregnancy 88 

Coccyx, Palpation of 95 

Rigid, interfering with labor 139 

Colostrum, Presence of 81, 126 

Commitment in cases of puerperal insanity 428-434 

Confinement, Date of 84, 139 

Contracted Pelves 277 

Border line cases of 302 

Craniotomy in 296 

in elderly primigravida 282 

Estimation of size of fetus in 278 



502 INDEX 

Contracted Pelves, High forceps in 158, 282, 290 

Summary of 301 

Constipation in newborn babies 493 

Contraction Ring 149 

in breech delivery 180 

High forceps in 158 

Convalescence following toxemia of pregnancy 322 

Convulsions in pregnancy 337 

Costo-vertebral tenderness 380, 386 

Counter Pressure on the head by assistant in forceps deliveries 169 

Cranial Bones, Fracture of 487 

Treatment of 487 

Craniotomy 296 

Technique of 298 

on the after-coming head 300 

Croton Oil in eclampsia 337 

Curettage, Finger 45 

Finger, in sepsis 368 

Length of time in bed after 36 

Instruments for 49, 363 

Intrauterine douche following 50 

Objections to, in sepsis 368 

in sepsis 362 

in sepsis, Technique of 367 

, Technique of 36, 48 

Vaginal examination after 36 

D. 

Date of confinement. Calculation of . 84, 139 

Decidual Cast 27 

Delivery of head. Means of hurrying 76 

Delivery of the head, Method of 114 

Delivery, Preparations for loi 

Delivery, Technique of normal 106 

in heart disease 409 

Diabetes in pregnancy 85 

Diaphoresis in eclampsia 344 

Diet in eclampsia 348 

in nausea and vomiting of pregnancy 306 

in puerperium 122 

in toxemia of pregnancy 315 

Digitalis, Use of, in heart disease in pregnancy 408, 412, 418 

Dilating Bags, Insertion of 443 

Instruments necessary for the insertion of 444 

Technique of inserting 444 

Use of 439 

Dilatation of the Blood Vessels over the abdomen in acute hydramnios 457 

Dilatation of the Cervix, Method of 163 

Dilatation of the Perineum in operative deliveries. Method of 162 

Dilators, Mechanical, Use of 34^ 



INDEX 503 

Page 

Disinfection of hands 106 

Distention of Bladder during labor 328 

Distention of Uterus in twin pregnancies, Danger of 208 

Diuresis in toxemia of pregnancy 332 

Douche, Intrauterine, following packing of the uterus for hemorrhage .... 232 

Use of, for stopping post partum hemorrhage 235 

following operative delivery 460 

Chill following 363 

in sepsis 362, 367 

Technique of 363 

Douche, Post partum, Use of 125 

Dry Labor 109, 140 



E. 

Eclampsia 313 

Blood pressure in 335 

Diet in 348 

Blurring of eyesight in 318 

Induction of labor by Voorhees bag in 313 

Palliative treatment followed by vaginal Caesarean section in . . . 337 

Post partum, treatment of 347 

Symptoms of 318 

Vaginal Caesarean section in 335, 339 

Edema, of the anus, Treatment of 461 

of the anterior lip of the cervix 151 

of the lungs in toxemia of pregnancy 313 

of the vagina 183 

of the vulva 332 

in hydramnios 460 

in mastitis 400 

Elastic Stocking, Use of, following phlebitis 375 

Elaterin in eclampsia 343 

Elbow, Presentation of 357 

Endocervicitis, as cause of bloody vaginal discharge 323 

Treatment of 417 

Epsom Salts, Use of, in toxemia of pregnancy 332 

Ergot, Use of, in post partum hemorrhage 232, 236 

Esbach's Albuminometer 85 

Ether in labor 130 

Ether, Obstetric 56, 61 

Exercises in the puerperium 66, 77, 129 

Exploration of the uterus following version 216 

Exploratory Puncture in mastitis 400 

External Version in breech presentations 191 

Extrauterine pregnancy 19 

Eyes, Care of the baby's, at birth 115, 482 

Eyesight, Blurring of, in eclampsia 318 

Eye Symptoms in nausea and vomiting of pregnancy 308 



504 INDEX 

F. 
^ ^ Page 

Face Presentation 351 

Causes of 355 

Chin anterior 353 

Management of chin posterior 356 

Treatment of 355 

Summary of 355 

Vaginal examination of 353 

Facial Paralysis, Cause of , 488 

False Labor 64, 74 

Femur, Fracture of, in breech deliveries 181 

Fetal Heart in breech deliveries 176, 190 

Importance of listening to 477 

Importance of listening to, in forceps delivery 166 

Increase in rate of 151 

Irregular, Low forceps for 136 

Irregularity of, in pregnancy 136, 413, 414 

Fetal Skull, Depression of 159 

Fillet, Use of 358 

in prolapsed arm 360 

in version 244 

Finger Curettage 45 

in sepsis 368 

First Stage, Management of, of labor 105 

Flat Pelvis '. . 229, 238 

High Forceps in 158 

Version in 240 

Fluids, Forcing of, in eclampsia 336 

Fluid Wave in hydramnios 457 

Fontanelle, Shape of anterior 164 

Shape of posterior 164 

Food, Aversion to, in early pregnancy 19 

in active labor 105 

Footling, Double 206 

Footling Presentation 174 

Forceps, Technique of, to after-coming head 240, 245 

Applications of, by one hand 166 

Delivery by I33 

Double application of 165 

High, Double application of 147 

High, Condemnation of 169 

Indications for 170 

Intermediate 280 

Low 133 

Low, occiput right posterior 139 

Removal of 167 

Tentative traction 166 

Forceps Delivery, Technique of 160 

Forcing of Water, Cause of high blood pressure in eclampsia 344 

Foreskin, Retraction of 483 



INDEX 505 

Page 

Fractures in the newborn, Treatment of 487 

Fresh Air, Necessity of, for the baby 481 

FuNDAL resistance in version 230, 242 



G. 

Glycosuria, transient 85 

Granuloma of the umbilicus. Treatment of 481 



H. 

Hallucinations in puerperal insanity 432 

Hamamelis, Use of, in hemorrhoids 461 

Head, Means of hurrying delivery' of 76 

Method of delivery of 114 

Treatment of molded 485 

Headache in pregnancy 337 

in toxemia of pregnancy 319 

Heart Disease, Labor in 419 

Normal delivery in 409 

Abortion in, in pregnancy 405 

Summary of, in pregnancy 418 

Heel, Grasp of, in version 243 

Hegar's Sign 33 

Hematoma of the sterno-mastoid 488 

Hemorrhage, Accidental, of pregnancy 248 

Causes of accidental 252 

Symptoms of accidental 252 

Treatment of accidental 254 

Summary of accidental, of pregnancy 252 

Importance of holding the uterus in 233 

Internal concealed 233 

following Braxton Hicks' version 273 

Management of 233 

Intracranial 485, 486 

following normal labor 74 

Control of post partum 229, 231, 257 

Intrauterine douche for post partum 235 

Causes of post partum 233 

Primary post partum 233 

Preparations for meeting post partum 235 

Management of post partum 233 

Secondary post partum 233 

Cause of secondary post partum 233 

Control of post partum 257 

Technique of stopping post partum 235 

Treatment of post partum 234 

in the third stage due to partially separated placenta. . 76 

in threatened abortion 37 

Treatment of, in pregnancy 269 

following twin pregnancy 206 



506 INDEX 

Page 

Hemorrhage, Unavoidable, of pregnancy 255 

Voorhees bag in accidental 250, 253 

Hemorrhagic Disease of the newborn 202, 283 

Prognosis of 483 

Signs of 483 

Rabbit serum in 484 

Transfusion in 484 

Treatment of 484 

Use of drugs in 484 

Hemorrhoids, Care of, in the puerperium 286 

Hexamethylenamine, Use of, in pyelitis 379 

High Forceps in contracted pelvis 282 

Human Serum, in hemorrhagic disease of the new born 484 

Hydramnios 455 

Acute 455, 462 

Causes of 462 

Chronic 462 

Danger to the mother in 464 

Diagnosis of acute 457 

Diagnosis of 463 

Dilatation of the blood vessels of the abdomen in acute 457 

Treatment of acute 458 

Labor in 464 

Fluid wave in , 457 

Placenta in 460 

Associated with multiple pregnancy 463 

High rupture of the membranes in 464 

Summary of the management of cases presenting 462 

Symptoms of 462 

Treatment of 463 

Malformations of the fetus in 463 

Hydrostatic Dilating Bags, Use of 439 

Summary of the use of 443 

Hyoscine Hydrobromate, Use of, in puerperal insanity 429 

Hypophysin, Use of, in post partum hemorrhage 236 

I. 

Ice, Use of, in post partum hemorrhage 232 

in mastitis 398 

Idiosyncrasy to morphia 47 

Imperforate Anus 488 

Induction of Labor in eclampsia, Method of 345 

Insufflation, Mouth to mouth 478 

Intercourse during pregnancy 89 

Frequency of, in pregnancy 24 

Interlocking of twins 209 

Internal Conjugate, Measurement of 95 

Internal Rotation of the shoulders 115 

Intracranial Hemorrhage, Prognosis in 486 

Signs of 485 

Treatment of 486 



INDEX 507 

Page 

Intrauterine Douche, Use of, for stopping post partum hemorrhage .... 235 

following packing of the uterus for hemorrhage. . . 232 

Intrauterine Douche 383 

Chill following 363 

in sepsis 362, 367 

Technique of 363 

Introitus, Blueness of 33 

Involution of the uterus in sepsis 366 

J. 

Jaundice of the newborn, Treatment of 484 

K. 

Kitchen Table, Use of, in operative delivery 230 

Knee Chest Position, Use of 23 

in retroverted uterus 23, 91 

in prolapsed cord 214 

L. 

Labor, complicated by cicatrix in the vagina 467 

Dry 109, 140 

Normal, characteristics of 65 

Normal, occiput right posterior 60 

Occiput left anterior 53 

Primiparous, occiput right posterior 79 

Type of 302 

Lacerated Perineum, Sepsis from 186 

Laceration of the sphincter ani 181, 185 

Lactation Atrophy, of the uterus 417 

Lateral Position, Low forceps in 219 

Laxatives, Use of, for the nursing woman 490 

Lay-out for the baby 477 

Length of Time in bed after delivery 128 

Lithotomy Position, Exaggeration of, to be avoided 161 

Lochia, Bacteriological examination of 369 

Care of 125 

Foul 362 

Retention of . 82, 364 

Treatment of retention of 71 

M. 

Macerated Fetus in hydramnios 460 

Malformations of the fetus in hydramnios 463 

Malpositions of the fetus in hydramnios 464 

Manual Dilatation, High forceps following 154 

of OS uteri 155 

in placenta praevia 273 

Manual Removal of the placenta 231 



508 INDEX 

Manual Rotation of the occiput In forceps delivery i68 

of occiput right posterior positions 155 

Massage in the puerperium 130 

Mastitis, Acute 58, 221, 393 

Use of breast pump in 393 

Onset of 397 

Prognosis of 398 

Summary of 397 

Symptoms of 387, 389 

Treatment of 393, 398 

Treatment of, of the newborn 484 

Mechanical Dilators, Use of 346 

Meconium, Unmixed, Significance of 414 

Medical Complications during pregnancy 475 

Membranes, DeHvery of 118 

Retained 68, 1 18, 234 

Retained, Technique of removing 69 

Early rupture of 217 

Rupture of, before labor 80, 147 

Mental Condition, Changes In, In pregnancy 32 

Menstrual History, Importance of, In the diagnosis of pregnancy 31 

Menstruation, Establishment of, after pregnancy 150, 417, 490 

Precocious 483 

Micturition after delivery 123 

Frequency of, following forceps delivery 416 

Increase of 31 

Milk, Use of modified 494 

Milk Sinus 402 

Milk Supply, Insufficient 493 

Miscarriage, See also Abortion 35 

Automobile 44 

Causes of 51 

Curettage of 45 

Incomplete 36 

curettage for 36 

Inevitable 42 

Packing of the cervix and vagina In 42 

Treatment of 42 

Pregnancy after 51 

Amount of flowing in threatened 38 

Morphia in threatened 35 

Threatened, Signs of 35 

Treatment of threatened 35 

Length of time in bed after 50 

Beginning of menstruation after 50 

Vaginal examination In 46 

Moulded Head, Treatment of 485 

Morphia, Idiosyncrasy to 47 

Use of, in eclampsia 315, 348 

In miscarriage 35» 47 

in post partum hemorrhage 232 



INDEX 509 

Page 

Mother's Outfit 99 

Movements, Baby's 493 

Multipara in labor, Vaginal examination of 69 

Multiple pregnancy 199 

Management of, Summary of 208 

N. 

Nausea and Vomiting of pregnancy 31 

Induction of labor in 308 

Return of 342 

Summary of 308 

Treatment of 306 

Nipples, Inverted 89 

Treatment of cracked 127 

Nitrous OxroE, Use of in Obstetrics 131 

Nursing, Beginning of 126 

during acute illness 491 

Contra-indications for 491 

in eclampsia 349 

Importance of 489 

Periods 492 

in sepsis 370 

Signs of insufficient 493 

Signs of successful 489, 492 

Nursing Woman, care of 490 

o. 

Obstetrical Ether, Use of 51,61, 279 

in breech deliveries 174, 191 

Obstetrical Paralysis, Cause of 488 

Treatment of 488 

Operative Delivery, Importance of obtaining history of 468 

Operative Obstetrics, Postion of the child in. Determination of 164 

Ophthalmia Neonatorum, Treatment of 482 

Orders to the nurse after a normal delivery 57 

Os Uteri, Manual dilatation of 143 

Outlet, Transverse diameter of 96 

Overriding of the head at the symphysis 301 

Ovum, Blighted 40, 42 

Oxygen, Use of, in asphyxia of the baby 479 

P. 

Packing of the uterus. Removal of, following post partum hemorrhage .... 236 

Pains, Cessation of, following rupture of membranes 65 

Palliative Treatment in eclampsia 338 

Palpation, Methods of 92 

of twin pregnancy 200 

Pelvic Examinations on discharge 128 

Pelvimetry 91 

Perineum, Inspection of, after delivery 119 

Laceration of 138, 150, 153, 284 



5IO INDEX 

Pessary, Removal of, during pregnancy 407 

Use of, in retroverted pregnant uteri 64 

in retroverted uterus 30 

in retroversion following delivery 66 

Phlebitis 373 

Ante-partum 43 

Signs of. 373, 375 

Use of pillow splint in 374 

Summary of 375 

Treatment of 375 

Use of elastic stocking following 377, 406 

Physician's Outfit in obstetrics 96 

Physician's Visits in the puerperium 127 

Pillow Splint, Use of, in phlebitis 374 

Pilocarpine a dangerous drug 344 

PiTUiTRiN, Use of 171, 251 

in post partum hemorrhage 236 

Placenta, Delivery of 62, 1 18 

Inspection of 118 

Manual removal of 231 , 274 

in acute hydramnios 460 

Low attached, Separation of , 259 

Premature separation of normally implanted 248, 250 

Separated 251 

Succenturiata 234 

Placenta Pr/Evia 255, 256 

Braxton Hicks' version in 272 

Csesarean section in 272 

Delivery of placenta in 273 

Diagnosis of 269 

Gauze pack in 272 

Manual dilatation in 256, 273 

Mortality in 274 

Palliative treatment of 270 

Prognosis for the child in 274 

Rights of the child in 270 

Rupture of the uterus in 274 

Summary of 268 

Treatment of 270 

Vaginal pack in 266 

Version in , 256, 267 

Voorhees bag in 266, 271 

Pneumonia complicating pregnancy 471 

Position of the child in operative obstetrics. Determination of 164 

Posterior Parietal Presentation 288 

Labor in 288 

Vaginal examination in 288 

Post Partum Hemorrhage 231 

Danger of infection following 237 

After care of the patient in 237 

Packing of the uterus with gauze in 235 

Potassium Citrate in pyelitis 381 



INDEX 511 

Page 

Pregnancy, Blood pressure in 53. 86 

Blueness of the introitus in 33 

Treatment of constipation in 40 

Depression in 32 

Diagnosis of 17 

Summary of diagnosis of 31 

Diet in 86 

Error in diagnosis of 22 

Exercise in 86 

Exhilaration in 32 

Heart disease in 405, 412 

in heart disease, Danger of 419 

Mental condition of patient in 32 

Mitral regurgitation in 412 

Nausea and vomiting of 405 

Objective signs of 33 

during nursing period 491 

Normal 53, 64 

Pyelitis in 379 

following pyelitis 387 

Signs of 18, 20 

Presumptive signs of, Value of 32 

Subjective signs of 32 

Sleepiness in 79 

Softening of the cervix in 33 

Increased vaginal secretion in 33 

Premature Baby, Care of 495 

Prenatal Care 83 

Pamphlet on, by U. S. Dept. of Labor 83 

Preparation of the patient 107 

for operative delivery 161 

Presenting Part, Overriding of 302 

Pressure Symptoms in hydramnios 462 

Presumptive Signs of pregnancy 31 

Progress of Labor by palpation 109 

Prolapse of the Arm, Use of the fillet in 360 

Prolapse, of the Cord, Postural treatment of 226 

Replacement of 224 

Version as operation of, election for 227 

Prolapsed Cord, Causes for 224 

Frequency of, in footling presentations 227 

Forceps delivery in 152 

Knee chest position in 214 

Low forceps in 217 

Management of 211, 214 

Occult 224 

Summary of 224 

Version in 211, 214 

Pubiotomy 303 

Puerperium, Chill in 221 

Exercises in the 66, 77, 129 



512 INDEX 

Page 

PuERPERiUM, Massage in the 130 

Pulse in the 122 

Pyelitis in the 379 

Retroverted uterus in the. Use of pessary 72 

Sepsis in 221 

Temperature during the 145 

Puerperal Insanity 425 

Cause of 435 

Consultation in 435 

Importance of nursing in 436 

Occurrence of pregnancy following 437 

Relapse in 433 

Treatment of 435 

Types of 435 

Summary of 434 

Puerperal Morbidity 122 

Puerperal Salpingitis 259, 261 

Summary of 261 

Pupils, Dilatation of, in puerperal insanity 428 

Pyelitis 379 

Differential diagnosis 384-386 

Importance of microscopic examination of urine in 386 

in pregnancy. Summary of 386 

Prognosis in 387 

in the puerperium 383 

in the puerperium, Summary of 386 

Treatment of 380, 387 

Changing reaction of the urine in .- 387 

R. 

Rabbit Serum in hemorrhagic disease of the newborn 484 

Rectum, Irrigation of, in eclampsia 344 

Religation of the cord 481 

Restitution of the baby's head 115 

Retroversion, Use of pessary in 90, 405 

Treatment of, by pessary in the puerperium 410 

after miscarriage. Treatment of 42 

Retroverted Uterus, Use of pessary in 30 

Robe Leg Holder 161 

Round Ligaments, Palpation of 28 

Rubber Gloves, Use of 107 

Rupture of the Membranes in acute hydramnios 458 

Method of 112 

in operative deliveries 164 

Technique of, with high head 69 

Ruptured Uterus 447 

Complete 451 

Incomplete 451 

Danger of, after Csesarean section 453 

Frequency of 451 



INDEX 513 

Page 

Ruptured Uterus, in placenta praevia 274 

Signs of 452 

Spontaneous complete 452 

Treatment of 448, 453 

Sepsis following 449 

Summary of 451 

Vaginal examination in 448 

S. 

Sacro Iliac Joint, Relaxation of 136 

Salpingitis, Puerperal 259, 261 

Puerperal, Summary of 263 

Salt Solution in eclampsia 336 

Use of, in post partum hemorrhage, intravenous and by 

rectum 236 

Scar Tissue in the vagina 468 

Scopolamine and Morphine anaesthesia in labor 421-424 

Second Stage of labor 112 

Seminal Secretion, Examination of 26 

Sepsis, Alcohol in 362-371 

Curettage in 362, 368 

Conservative treatment of 364, 367 

Ergot in 361, 364, 367 

Foul, lochia in 362, 366 

Intrauterine douches in 362, 368 

from lacerated perineum 186 

Prevention of 367 

in the puerperium 221 

following ruptured uterus 449 

Radical treatment of 367, 368 

Signs of 365 

Symptoms of 365, 366 

Treatment of 365-371 

Use of vaccines in 369 

Shaving of the vulval hair 104 

Shock after delivery 156 

after normal delivery 77 

following operative delivery 285, 414 

Shoulder, Presentation of 206 

Shoulders, Internal rotation of 115 

Silver Nitrate, Use of, as preventive of ophthalmia 482 

Skin, Care of, in pregnancy 88 

Smellie's Scissors 298 

Sphincter Ani, Laceration of 181, 185 

Sterile To\\^ls, Use of, in delivery 113 

Subconjunctival Hemorrhage, Cause of 488 

Treatment of 488 

SuBGALLATE OF BiSMUTH, Use of, in the treatment of the umbilical cord. . 480 

Sugar in the urine 85 

Suppositories, Use of, in the puerperium 123 



514 INDEX 

Page 
Supra Pubic Pressure, Technique of 195 

Surgical Complications during pregnancy 476 

Symphysis, Palpation of the angle of 96 

Relaxation of 147 

T. 

Technique of vaginal examination in left lateral position 107 

Teeth, Care of, in pregnancy 87 

Tentative Traction 149 

Tongue Traction as stimulus to respiration 479 

Toxemia of Pregnancy 313 

Csesarean section in 339 

Blood pressure in 325 

Induction of labor 318, 321 

Palliative treatment of 313, 325 

Symptoms of 325, 331 

Treatment of 343 

Urine examinations in 326 

Traction Rods, Use of 169 

Transfusion in hemorrhagic disease of the newborn 484 

in post partum hemorrhage 237 

Transverse Presentations 357 

Liability to prolapse of the cord in 359 

Summary of 359 

Treatment of 358 

Twin Pregnancy, Prognosis in 208 

Twins, Diagnosis of 208 

Twins, Interlocking of 209 

U. 

Umbilical Cord 352 

Dressing of 480 

Management of, when about the neck 56, 115 

Presenting 224 

Prolapse of 152 

Religation of ... 78 

Separation of 58 

Treatment of 481 

Umbilicus, Granuloma of, Treatment of 481 

HeaUng of 146, 480 

Normal 480 

Urates, Deposit of, on the diapers 483 

Urination (see Micturition). 

Urine, Amount of, in pregnancy 85, 342 

Examination of, in pregnancy , 85 

in pyelitis 379 

in toxemia of pregnancy 317, 318, 326 

Changing reaction of, in pyelitis 387 

Retention of 285, 329, 362 

Uterus, Abnormal contractions of 250 

Action of, in first stage 105 



INDEX 515 

Page 

Uterus, Action of, after labor 56 

Condition of, in sepsis 364 

Enlargement of, in pregnancy 33 

Holding of, after delivery 119 

Incarcerated pregnant 40 

Intermittent contractions of 33 

Lactation atrophy of 73 

Packing of, for hemorrhage 231, 235 

Relaxation of 207 

Retroversion of, in pregnancy 23 

Ruptured 447 

Ruptured, Complete 451 

Incomplete 451 

Danger after Caesarean section 453 

Frequency of 45 1 

in placenta praevia 274 

Signs of 452 

Spontaneous complete 452 

Treatment of 448, 453 

Sepsis following 449 

Summary of 451 

Vaginal examination in 448 

Tenderness of 253, 284 

Tonic contractions of 151 , 284 

V. 

Vaccines, Use of, in sepsis 369 

Vaginal Caesarean section 335, 339, 347 

in heart disease 419 

Vaginal Cicatrix, Causes of 468 

Vaginal Douches in labor 105 

Vaginal Examination at the beginning of pregnancy 90 

Danger of 108 

in left lateral position 107 

Importance of, when the membranes rupture 226 

by nurses 104 

of outlet of the pelvis 94 

of the pelvic cavity 94 

Vaginal Secretion, Increase of 33 

Varicose Veins, Use of elastic stocking in 407 

Treatment of, in pregnancy 406 

Veratrum Viride in eclampsia 337, 338 

Version 229 

Braxton Hicks', in placenta praevia 272 

Contra-indications for 244 

Elective version 238, 240 

Exploration of the uterus following 216, 244 

Indications for 241 

in face presentation . . 35i 

Position of patient in 242 

Preparations for 242 



5l6 INDEX 

Page 

Version, Spontaneous 175, 191 

Technique of 231 , 241 

Vomiting of pregnancy, Pernicious 311 

VooRHEEs Bag 439 

Use of, in acute hydramnios 458 

Capacity of 445 

Complications following use of 446 

in placenta prsevia 271 

Fetal heart following insertion of 441 

Technique of inserting 440 

Traction on 445 

in transverse presentations 360 

Use of .... 413 

Vulva, Care of the baby's 482 

W. 

Walcher's position 159 

Weaning, Method of 493 

Wet Nurse, Use of 46 






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